Every finding on record at Fairview Healthcare Residence

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 6 residents (Resident #3, Resident #19, Resident #32, and Resident #33) reviewed for infection control.The facility failed to supply staff with proper eye/face PPE for Resident #19 who was in droplet isolation during an observation of supplies on 08/05/2025.MA C failed to properly sanitize the blood pressure cuff after use on Resident #3 and Resident #33 during an observation of medication administration on 08/06/2025.MA C touched medications with her fingers prior to administration to Resident #38 during an observation of medication administration on 08/06/2025.This failure could place residents at risk for infection by the spreading of germs that could lead to illness and hospitalization. Findings included: Resident #19Record review of undated facility face sheet reflected Resident #19 was admitted to the facility on [DATE]. Medical diagnosis included Hemiplegia and Hemiparesis following cerebral infarction (paralysis caused by a stroke), Covid 19, Malignant Neoplasm of the Prostate (prostate cancer), and Diabetes Mellitus type 2. Record review of Resident #19's Quarterly MDS dated [DATE] reflected a BIMS score of 12 indicating moderate cognitive impairment. Record review of Resident #19's care plan dated 07/27/2025 reflected he tested positive for covid 19 on 07/27/25 and interventions included Quarantine in their room. Notify family and encouraged to limit visitation and to wear masks while in the facility, full PPE when in a positive resident's room. Droplet and contact precautions.In an observation 08/05/2025 at 9:45am 4 (four) white plastic bins were located outside of rooms in the hallway. The bins contained PPE, blue gowns and surgical mask. Resident #19 had a sign on his room door indicating he was in isolation with droplet precautions. Staff were observed going in and out of Resident #19's room not wearing face shield or eye protection. There were no face shields or eye protection available/accessible for staff in the PPE bins.Resident #3Record review of undated facility face sheet reflected Resident #3 was admitted on [DATE]. Diagnosis included Heart Failure, Hyperglycemia (elevated blood sugar), Hypertension (elevated blood pressure), and Lack of Coordination. Record review of Resident #3's care plan dated 06/09/2024 and updated 12/27/2024 reflected an alteration in cardiovascular status (a disease process affecting the heart). Interventions included to monitor Vital Signs (blood pressure, heart rate, respirations, and temperature) everyday as ordered. Notify physician of any abnormal readings.Record review of Resident #3's quarterly MDS dated [DATE] reflected a Bims score of 15 indicating he was cognitively intact. In an observation of medication administration on 08/06/2025 at 9:44 AM, MA C checked Resident #3's blood pressure using an electronical wrist cuff. MA C completed the check and cleansed the blood pressure cuff with alcohol-based hand sanitizer and nose tissue. Resident #33 Record review of undated facility face sheet reflected Resident #33 was admitted on [DATE]. Diagnosis included Major Depressive Disorder, Hyperglycemia (elevated blood sugar), Anxiety, and Hypertension (elevated blood pressure).Record review of Resident #33's care plan dated 05/05/2025 reflected an alteration in cardiovascular status. Interventions included to Obtain blood pressure readings as ordered. Take blood pressure readings under the same conditions each time. For example, resident is sitting, use right arm.Record review of Resident #33's quarterly MDS dated [DATE] reflected a Bims score of 14 indicating she was cognitively intact. In an observation of medication administration on 08/06/2025 at 9:56AM, MA C checked Resident #33's blood pressure using an electronical wrist cuff. MA C completed the check and cleansed the blood pressure cuff with alcohol-based hand sanitizer and nose tissue. Resident #32Record review of undated facility face sheet reflected Resident #32 was admitted on [DATE] and readmitted on [DATE]. Diagnosis included Senile Degeneration of the Brain (a disorder of the brain resulting in confusion), chronic kidney disease (failure of the kidneys), Major Depressive Disorder (depression), and Lack of Coordination. Record review of Resident #32's quarterly MDS dated [DATE] reflected a Bims score of 14 indicating she was cognitively intact. Record review of Resident #32's care plan dated 06/09/2024 reflected an alteration in respiratory status. Goals included The resident will be free of signs of respiratory infections through review date. Interventions included Monitor/document/report to MD PRN any signs of respiratory infection Fever, Chills, increase in sputum (document the amount, color and consistency), chest pain, increased difficulty breathing (Dyspnea), increased coughing and wheezing.In an observation of medication administration on 08/06/2025 at 10:10AM, MA C prepared Resident #32's medication for administration pushing her Thermotab (a medication administered to maintain sodium levels in the body) 1 tablet out of the multiple dose bottle with her bare fingers. In an interview on 08/07/2025 at 12:50 PM, MA C stated normally there were some types of disinfected wipes on the medication cart. MA C stated the facility kept a stock of disinfectant blue top wipes in the supply closet on the left side in storage, but staff did not have a key to access the supply room to obtain the wipes. MA C stated not using the proper disinfectant on equipment such as the blood pressure cuff could spread germs from one resident to another. MA C stated medications should not have been touched without gloves on, but the pill was stuck, and it would not come out of the bottle. MA C stated touching medication with unclean hands could lead to the spreading of infection. In an interview on 08/07/2025 at 12:55 PM, LVN A stated the facility had not provided eye covers, or face shields for staff to use in the droplet isolation rooms. LVN A stated she did not question the need for the eye shields because it had been so long since the facility had infections in the building that require the use of eye coverage. LVN A stated the risk for not using proper PPE when a resident was on droplet precautions would be spreading of the infection. In an interview on 08/07/2025 at 1:01 PM, the ADON stated she was the infection preventionist for the facility. The ADON stated the face shields were in the supply room and the staff could acquire them if needed. She stated not wearing proper PPE could increase chances of spreading germs. The ADON stated the MAs were expected to use proper sanitizing wipes when cleaning medical equipment that were located in the supply room. The medication aides are not expected to touch medications with their bare hands; they need to wear gloves and clean their hands if a medication were stuck in the bottle. The ADON stated not cleaning with appropriate disinfectant wipes and touching medications with their bare hands would allow for contamination of the medications and spreading of infections.In an interview on 08/07/2025 at 1:19 PM, the DON was responsible for monitoring infection control, and it was her expectation infection control polices be followed. The DON stated the risk to residents by not following proper infection control practices was spreading germs. Record review of facility policy titled Coronavirus Disease (Covid 19)-Using Personal Protective Equipment dated 2001 and revised September 2022 reflected: Personal protective equipment is provided to all employees, contractors, and volunteers free of charge.a. Eye Protection:(1) Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) is applied upon entry to the resident room or care area.(a) Protective eyewear (e.g., safety glasses, trauma glasses) with gaps between glasses and the face do not protect eyes from all splashes and sprays.(b) Ensure that eye protection is compatible with the respirator so there is not interference with proper positioning of the eye protection or with the fit or seal of the respirator.(3) Eye protection is removed after leaving the resident room or care area.(4) Disposable eye protection is discarded after use.Record review of facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment dated 2001 and revised September 2022 reflected: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard.a. Non-critical items are those that come in contact with intact skin but not mucous membranes.(l) Non-critical resident-care items include bedpans, blood pressure cuffs, crutches, and computers.(2) Non-critical environmental surfaces include bed rails, bedside tables.(3) Non-critical items require cleaning followed by either low- or intermediate-level disinfection following manufacturers' instructions. Disinfection is performed with an EPA-registered disinfectant labeled for use in healthcare settings. All applicable label instructions on EPA registered disinfectant products are followed (e.g., use-dilution, shelf life, storage, material compatibility, safe use, and disposal).a) Low-level disinfection is defined as the destruction of all vegetative bacteria (except tubercle bacilli) and most viruses, some fungi, but not bacterial spores. Examples of low-level disinfectants include EPA- registered hospital disinfectants with a HBV and HIV label claim. Low-level disinfection is generally appropriate for most non-critical equipment.b) Intermediate-level disinfection is traditionally defined as destruction of all vegetative bacteria, including tubercle bacilli, lipid and some nonlipid viruses, and fungi, but not bacterial spores. EPA-registered hospital disinfectants with a tuberculocidal claim are intermediate-level disinfectants. Intermediate-level disinfection is considered for non-critical equipment that is visibly contaminated with blood. However, a low-level disinfectant with a label claim against HBV and HIV may also be used.

Based on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment for 1 of 1 resident (Resident #10) reviewed for environment. 1. The facility failed to ensure Resident #10 room floors on halls 100 did not have a buildup of stains and physical dirt, scratches, peeling and chipping paint on the walls. 2. The facility failed to ensure the furniture wood was not chipping in room # 108A for Resident #10. These failures could place residents at risk of a diminished quality of life. [NAME], [NAME] (47243) - EnvironmentFindings included: Review of the undated face sheet for Resident #10 reflected an [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease (Alzheimer's disease is the biological process that begins with the appearance of a buildup of proteins in the form of amyloid plaques and neurofibrillary tangles in the brain), hypothyroidism (Hypothyroidism happens when the thyroid gland doesn't make enough thyroid hormone), hyperlipidemia (is an excess of lipids or fats in your blood), depressive disorder (are characterized by persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities), anxiety (a feeling of worry, nervousness, or unease about something with an uncertain outcome), and hypertension (a common condition that affects the body's arteries. It's also called hypertension).Review on the quarterly MDS assessment for Resident #10 dated 08/23/24 reflected a BIMS score of 03, indicating severe cognitive impairment. It also reflected she required supervision/touching assistance in the activity of dressing. Observation and interview with Resident #10 on 08/05/2025 at 10:41 AM revealed the floor trim detached from the wall, hanging off wall, walls and dresser draws with scratches, chipping and peeling paint, had deep scratches on the walls and doors and doorways. Resident #10 stated the scratches in the paint were ugly. She stated she do not want to complain because she was just admitted to the facility, but she did not feel she should have to live like that. Observation of the hallways in the facility on 08/05-07/25 revealed there were no floor trim coming off wall hanging off wall detached from wall, walls with scratches and peeling paint deep gouges in doors. However, there was hallways with half painted walls. Interview on 08/07/25 at 10:10 AM, the MAINT revealed the CNAs were usually responsible for cleaning the residents' rooms. He stated he remodeled the rooms when there were not any residents in them. He stated the baseboards were cove based and needed to be repaired. He stated that wallpaper on the walls and it needed to be repaired. He stated the intent was to be done with painting in the halls, but it was the wrong color. He stated he checked the daily logs, and he was the only one doing repairs. He stated he was the only one doing repairs according to the urgency and everyone pitched in to help him paint the facility. Interview on 08/07/25 at 10:35 AM, the ADM revealed the expectation was for maintenance to fix whatever was broken. He stated housekeeping was expected to clean. He stated if the resident was out of the room, housekeeping could deep clean the room. He stated housekeeping picked two rooms and deep cleaned them daily. If there was an infection outbreak, the expectation was to deep clean those rooms daily to keep it from spreading. He stated if the rooms were not clean it could make the resident feel bad. He stated they were picking rooms systematically. During a slower workday, everyone would pitch in to assist with getting some of the rooms done. Interview and observation on 08/07/25 at 11:50 AM, the HSKE revealed she was the supervisor, and she made sure all her staff deep cleaned 2 rooms a week. She stated the staff used a disinfectant spray and wiped down everything. She stated when the residents were not in the room, they wipe down the beds and mattresses. She stated maintenance did all the broken items repairs. She stated there was a book at the nurses' station and they wrote all the repairs that needed to be done in the book, and he looked at it daily. She stated when they were going into the COVID positive rooms, they cleaned them last. She stated her staff gown up and sanitize. They disinfect and clean up everything. Record review of the facility's, undated, policy on Residents Rights reflected .You have a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Review of facility policy dated February 2021 and titled, Homelike Environment reflected the following: Residents are provided with a safe, clean, comfortable, and homelike environment, and encouraged to use their personal belongings to the extent possible.

Based on interview and record review, the facility failed to transmit and ensure an MDS was completed and electronically transmitted to the CMS System for within 14 days, after completion resident assessment within the required time frame, for 1 of 6 (Resident #19) residents reviewed for data transmission in that: The facility failed to complete and transmit Resident #19's quarterly MDS completed on 07/05/25. This failure could place residents at risk of not having their assessments transmitted timely and an incomplete record. Findings included:Record review of undated facility face sheet reflected Resident #19 was admitted to the facility on [DATE]. Medical diagnoses diagnosis included Hemiplegia and Hemiparesis following cerebral infarction (paralysis caused by a stroke), Covid 19, Malignant Neoplasm of the Prostate (prostate cancer), and Diabetes Mellitus type 2. Record review of Resident #19's quarterly MDS assessment dated [DATE] reflected the MDS had been completed but was not transmitted. In an interview on 08/07/2025 at 1:41PM, the MDSC stated she was not sure why Resident #19's quarterly MDS from 07/05/2025 was not transmitted. She stated the MDS was checked do not transmit. The MDSC stated that she was responsible for the transmission of the MDS but there was a system error. Record review of policy titled Electronic Transmission of the MDS dated 2021 and revised October 2023 reflected All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records are completed and electronically encoded into our facility's MDS information system and transmitted to CMS' Internet Quality Improvement and Evaluation System (iQIES) system in accordance with current OBRA regulations governing the transmission of MDS data. All staff members responsible for completion of the MDS receive training on the assessment, data entry, and transmission processes, in accordance with the Resident Assessment Instrument (RAI) User's Manual, before being permitted to use the MDS information system. A copy of the RAI User's Manual is maintained by the resident assessment coordinator.

Based on observations, interviews, and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 of 5 residents (Resident #4) reviewed for accuracy of assessments.The facility failed on 6/8/2025 to accurately code Resident #4's hearing ability on his comprehensive MDS assessment.This failure could place residents at risk of incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings included:Record review of Resident #4's comprehensive MDS, dated [DATE], indicated Resident #4 was a [AGE] year-old male, who was admitted to the facility on [DATE]. His diagnoses included: stroke (when a blood vessel in the brain leaks or bursts and causes bleeding in the brain), aphasia (inability to speak well), dysphagia (difficulty swallowing), hemiplegia (total or nearly complete paralysis on one side of the body) and muscle wasting and atrophy.Resident #4 did not have a BIMS score as question ‘C0100. Should Brief Interview for Mental Status be conducted? Was indicated as ‘0. No (resident is rarely/never understood)'. In ‘Section B Hearing' question B0200 indicated that Resident #4 was Highly impaired - absence of useful hearing and question B0700 indicated that Resident #4 was rarely/never understood. Record review of Resident #4's comprehensive MDS, dated [DATE], reflected that Resident #4 did not have a BIMS score as question ‘C0100. Should Brief Interview for Mental Status be conducted? Was indicated as ‘0. No (resident is rarely/never understood)'.In ‘Section B Hearing' question B0200 indicated that Resident #4 had Adequate - no difficulty in normal conversation, social interaction, listening to TV' and question B0700 indicated that Resident #4 was ‘Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time.Record review of Resident #4's care plan dated last revised 07/28/2025 reflected Resident #4 was very hard of hearing, could read lips, would communicate with head nods, and had a communication problem related to difficulty hearing and aphasia. Interventions included staff to look directly at him and talk slow so he could understand and give him time to process due to the stroke. Record review of a nursing note dated 09/01/2021 reflected, Resident admitted via EMS with personal belongings-hearing aide x1 placed inside table drawer. Unable to speak or help turn-total care x2. Does not appear to be in any pain. Resident is deaf but reads lips- does not appear to understand what is being asked of him and does not follow commands at all.Record review of Resident #4's weekly nursing summary dated 07/29/2025 reflected in section ‘D. Communication'Question ‘1. Ability to express ideas and wants, consider both verbal and non-verbal expression' was answered with ‘3. Rarely/never understood.'. Question ‘1a. If impaired ability to make self-understood, choose the example that applies' was answered with ‘5) Unable to make needs known, all needs anticipated and met by staff.Question ‘2. Ability to hear (with hearing aid or hearing appliances if normally used)' was answered with ‘3. Highly impaired'Record review of Resident #4's progress note dated 07/29/2025 reflected, Resident's responsible party had inquired about hearing testing services. Resident to be referred to [hearing aid center] that services nursing home residents. Face sheet sent to [hearing aid center] for implementation of referral process.In an observation and attempted interview on 08/05/2025 at 10:31 AM Resident #4 was in his bed asleep and did not arouse when the surveyor was talking or nearing his bedside. After about 30 minutes of the state surveyor speaking with Resident #4's roommate, Resident #4 appeared to be awake. When asked by the surveyor about his stay at the facility, his care, and his daily activities, Resident #4 just blankly stared at the surveyor and did not respond with head gestures or words. In an additional attempted interview and observation on 08/06/2025 at 11:17 AM Resident #4 was lying in bed revealed when the state surveyor asked him how he was doing, he had a blank stare and shook his head in a ‘no' motion about 45 seconds after being asked. When the state surveyor asked for permission to check his bedside table for hearing aids, he slowly moved his head to look in the direction of the surveyor's finger, but he did not respond with head movements or words. In an interview on 08/06/2025 at 11:29 AM with LVN A she stated she had worked at the facility almost 4 years. She stated that Resident #4 never pressed his call light. She stated that he worked with occupational therapy, received tube feedings, and that when the aides provided check and change of undergarments, he could hold the bed rail with his one good side. She stated that he was able to understand the staff, but he was not able to communicate his needs at all due to his diagnosis of stroke. She stated that he was not a big fan of being up out of bed. She stated that when Resident #4 first admitted , he had hearing aids , but she was unsure what happened with them, and she stated he was able to hear based on his ability to help during check and change. In an interview/observation on 08/06/2025 at 11:43 AM with CNA B she stated she had worked at the facility for about 5 years. She stated that a restorative aide works with Resident #4 in his room and that Resident #4 stopped using his call light at the beginning of 2025. When asked, she stated that the only things he would be using his light for was to notify of needing to have his brief changed or wanting to get into his wheelchair. CNA B then asked the state surveyor how the resident was supposed to communicate with the staff if he was deaf and could not press his call light now, and how the staff were supposed to know what he needed. The surveyor advised her to speak to her DON. CNA B stated that Resident #4 used to have hearing aids when he first admitted , the CNA's were responsible for putting them in and taking them out. She was not sure what happened to them. She showed the surveyor 1 hearing aid located in a sealed container in Resident #4's dresser. In an interview on 08/07/2025 at 9:31 AM with the DOR and the MDSC, the DOR stated that physically Resident #4 was able to press the call light, but he chose not to. She stated that he could grasp and lift 3lb weights, so they knew he was able to press the call light as well. She stated that he could help dress himself and that he would laugh and communicate by head gestures and smiles during therapy sessions. When the MDSC was asked why Resident #4 was marked as having adequate hearing this year versus being highly impaired last year, she stated that she was not the MDSC when his last year's assessment was conducted, but that this year she had interviewed him, and he had smirked at her, and nodded at her. The DOR stated she thought it was because he was reading lips, not because he was able to hear.In an interview on 08/07/2025 at 9:47 AM, the DON stated Resident #4 was put on the hearing aid referral list on 7/29/2025, she stated that they went through and assessed the residents who could benefit from being seen by the hearing aid company. She stated that Resident #4 had hearing aids in the past, but they were unable to determine if the hearing aids were working upon admission. She confirmed that he had a hearing impairment, and it was documented in the clinical record that he was deaf. In an interview on 08/07/2025 at 12:35 PM with the MDSC she stated that they did not have an MDS Accuracy policy, they just referred to the RAI Manual. Review of the Long-Term Care Facility RAI 3.0 User's Manual dated last revised October 2024 reflected, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 2 medication carts reviewed.The facility failed on 07/27/2025 to sufficiently record the accurate reconciliation of controlled substances.This failure could place residents at risk of misappropriation of resident medication.Findings included:Record review on 08/05/2025 at 2:07 PM of the [NAME] wing medication cart's narcotic sign on and sign off sheet revealed that LVN E failed to sign that the narcotics were counted with LVN D when LVN E assumed the medication cart on 7/27/2025, and when she handed off the medication cart at the end of her shift on 7/27/2025 to LVN D.In an interview on 08/05/2025 at 2:30 PM with LVN D she stated that she always signed off with someone when doing the narcotic count. She stated that 2 people always counted the cart, it was required that the person coming on shift and the person going off shift, were to count the cart together and sign that it was done. She stated she passed the cart off to LVN E on 7/27. She stated that immediately after counting they were supposed to sign off on the narcotic sign on and sign off log. She stated that once she finished counting, and signed the narcotic log, she did not stand there to watch the other person sign. She stated the purpose of counting the narcotics was to keep an accurate count of the narcotics and verifying that all medications were accounted for. She stated it helped if there was a medication discrepancy, they would know who worked. She stated a negative outcome was that if medications were not accounted for it was an issue of misappropriation. If she had a discrepancy in count, she had to immediately notify her DON. In an interview on 08/06/2025 at 1:10 PM with LVN E she stated that she had worked at the facility for about 5 years and recently went PRN. She stated that she did always count the cart at the beginning of her shift with the outgoing nurse and then she would count the cart at the end of her shifts with the oncoming nurse. She stated that she did not know why she did not sign the sign off sheet on 07/27/2025 but that it was hers and the facility's practice to not assume the medication cart until counting with the prior shift nurse. She stated that it was the responsibility of both the outgoing nurse and the oncoming nurse to sign the log as proof of the narcotics being counted together. She stated that a negative outcome would be that it could appear that the narcotics were not being counted amongst the shift changes. In an interview on 08/07/2025 at 9:17 AM with the DON she stated the purpose of the narcotic sign on and sign off log was to verify that the narcotic count on the cart was correct. When asked what would blanks on the narcotic log indicate to her, she stated that she would first question if a 2-person count occurred, but ultimately it would tell her if the cart was properly counted by the outgoing and ongoing nurse. She stated that signing the log was for quality control measures, and it could affect the residents' if their medications were not being counted and if doses were missing. She stated it was the responsibility of both nurses to sign the log when handing it off and when assuming it. She stated they (DON or ADON) should verify the logs weekly. She stated that when the sheet ran out of space, it would be turned into and verified by the ADON or DON.Review of the facility's policy titled ‘Controlled Substances' dated July 2025 reflected: Controlled substances are counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals sign the designated controlled substance record.The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 (Resident #1) of 5 residents reviewed for abuse. The facility failed prevent CNA A, on 01/20/25, from physically abusing Resident #1 when she approached Resident #1 in an aggressive manner and pushed into residents abdominal and chest area with her stomach. CNA A shoved Resident #1 in the right arm and in the back into the hallway 01/20/25. On 04/08/25 at 6:00 PM, an Immediate Jeopardy (IJ) was identified. The IJ template was provided to the facility on [DATE] at 6:13 PM. While the IJ was removed on 04/09/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of emotional distress, fear, decreased quality of life, psychosocial harm, trauma, and abuse. Findings included: Record review of Resident #1's admission record dated 04/08/25 reflected Resident #1 was a [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses including dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), diabetes (a group of diseases that result in too much sugar in the blood), anxiety (intense, excessive, and persistent worry and fear about everyday situations), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood). Record review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS score of 10 indicating moderately impaired cognition. Quarterly MDS reflected Resident #1 was independent for eating, toileting, and personal hygiene and required set-up or clean up assistance for bathing. Record review of Resident #1's care plan initiated 01/20/25 reflected, Resident #1 has a behavior problem r/t psychotic and mood disturbances as well as anxiety. Verbal and physical. She thinks staff and other residents are taking her things and talking about her. Makes false allegations towards staff. She has exhibited verbal and physical aggression toward staff. Interventions initiated 01/21/25 and revised 01/23/25 included Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Care plan initiated 11/15/21 and revised 06/06/24 reflected Resident #1 has impaired cognitive function/impaired thought processes r/t Dementia. Interventions initiated 02/06/21 and revised 01/21/25 included If resident is agitated staff should leave resident in a safe environment and then reapproach resident after time to allow her to be redirected. Record review of the weekly skin assessment notes from 01/17/25 reflected Resident #1 had healing scattered faint bruising to BUE. Review of the weekly skin assessment notes from 01/24/25 reflected Resident #1 had healing scattered faint bruising to BUE, purple bruise noted to Lt. wrist 2.0 cm x 4.0 cm and left outer knee 4.0 cm x 2.0 cm bruise fading. Review of the weekly skin assessment notes from 01/31/25 reflected Resident #1 had fading scattered bruises to upper BUE and BLE. In an interview and observation on 04/07/25 at 4:15 PM, Resident #1 was in the common area of the secure unit sitting on a couch watching TV. Resident's appearance was good with no physical signs of abuse or neglect noted. Resident #1 exhibited no signs or distress or discomfort. Resident confirmed her identity when asked. Resident #1 stated that she felt safe and was not afraid of any resident or staff member at the facility. Resident stated that she was from the area and went to the local high school and could take care of herself. When asked if she had any recent incidents or altercations with staff the resident said she could not remember. In an observation and interview on 04/08/25 at 3:41 PM, Resident #1 stated she was doing fine. She stated she was [AGE] years old, and no one had hurt or bothered her, and she could take care of herself. Resident #1 appeared clean and groomed and showed no signs of pain or distress. During an interview on 04/07/25 at 11:14 AM with the ADM, he stated the employee involved in the incident was still employed with the facility. CNA A was reassigned from the secure unit. The ADM stated that the video was no longer available. During an interview on 04/07/25 at 2:27 PM, the DON stated she had reviewed the video because she was looking into another incident, and someone had already reported this incident. She stated she saw and heard CNA A asked about moving a chair and Resident #1 said no while getting loud. The DON said CNA A pushed the chair toward Resident #1 to put space in between them. The DON also said they went chest to chest. The DON was asked to see the video the DON reviewed, and she agreed . During an interview on 04/07/25 at 2:40 PM with the ADM and the DON returned in response to state surveyor's request for video. The ADM had the video on his cell phone and allowed surveyor to review it. The ADM and DON agreed to send surveyor a copy of the video. Asked what their policy was on disciplinary action and what was their reasoning for not terminating CNA A. They stated they felt CNA's move to the regular unit where she would be monitored by nurse and other staff would be sufficient. Asked them to continue to try reach CNA A and ask her to call me because I would like to interview her personally. The DON stated she would try to reach her. In an interview on 04/07/25 at 3:51 PM, CNA A stated she had worked in the facility for about five years, and she had been a CNA for [AGE] years. She stated she had never been reported for abuse. She stated she had not done anything bad and being burnt out is what caused this to occur. She stated it was not her fault. She stated she worked the night shift (6 pm to 6 am) together with a nurse often. She stated working nights was not easy and had been getting to her, especially with it being twelve hour shifts. She stated residents usually started with sundowners when she came in to work and it was chaotic. She stated residents became anxious and the nurse was usually getting medications to the residents, and she was in the nutrition room and cared for residents. She stated it was nothing unusual going on that day 01/20/25, and about 9 pm she had begun putting chairs out for the residents to sit at while the nurse gave out medications with snacks. She stated she went down the hall and came back and Resident #1 began doing her usual thing, which was moving things around. She stated she went back in the nutrition room and told the resident that she needed the chairs to be left in place and Resident #1 began arguing. She stated she told resident again about the chair and took the chair away from the resident. She stated the resident jumped up and began yelling and cursing and grabbed the chair. She stated she told the resident that the chair needed to be left where she had put it. She stated the resident slapped her with both hands. She stated she yelled for the nurse and started walking away and resident came at her and swung again. She stated she grabbed the resident behind her shoulders to stabilize the resident. CNA A stated she was hurting, and when she called for the nurse, she cussed when yelling that Resident #1 had slapped her across the fucking face. She stated she should have walked away. She stated she walked over to the rail on the wall with the resident and walked off at that point. She stated she told the nurse to call the DON and to tell her that resident had slapped her. She stated she was not cussing at Resident #1, and she would have usually walked off in that situation. She stated she was bruised on her left cheek for 3 days. She stated she should have walked away. She stated it was frustrating when she did not have a lot of help. She stated she told the DON a couple of months before that she was burnt out and it was becoming too much for her to work back in the secure unit. She stated there was an incident before where she was talking loud over a resident, and someone said she had been rude, and it was looked into. She stated she disclosed she had felt burnout. She stated she was in-serviced on abuse and neglect, and interventions in these types of situations would be to walk away. In an interview on 04/07/25 at 5:09 PM, CNA B said she had been employed at the facility for five years. She said she had been trained and in-serviced on abuse and neglect. CNA B said if she was to observe abuse or neglect she would report this to the nurse or administrator. She said the administrator is their abuse coordinator. CNA B denied ever observing abuse or neglect while working at the facility. In an observation on 04/08/2025 at 10:00 AM of video footage which included sound from incident regarding alleged abuse, video revealed Resident #1 was moving a chair from the side of the wall when CNA A walked over to resident while pointing at the table and telling resident to put it back at the table. CNA A pulled the chair out of residents hand and Resident #1 attempted to hit CNA A in stomach area. CNA then walked toward and into Resident #1's body, pushing resident back some. Resident #1 slapped CNA A on the left side of her face. CNA A turned around with her hand on the left side of her face and called for the charge nurse, yelling resident had just slapped her in the face. CNA A then turned back around. Resident #1 was walking past CNA A and CNA A grabbed resident by her right arm and shoved Resident #1 toward the hallway. CNA A walked into hallway behind Resident #1 and continued shoving Resident #1 toward wall and side handles on the wall. Once CNA A got Resident #1 to side handles she walked away from resident and continued yelling for the charge nurse. When charge nurse approached CNA, the CNA told the charge nurse that Resident #1 had slapped her in the fucking face. In an interview on 04/08/2025 at 12:51 PM with the CRN, he stated anytime a situation like this arose he would start by putting himself in the employees' place and then in the resident's place. He stated he observed the video of the incident, and the resident was standing by the table. He stated the CNA rushed over concerned the resident was going to fall and the resident did not like the interaction. He stated the resident started making punching motions toward CNA's stomach area and then slapped the CNA. He stated resident may have episode of being violent and was care planned for that and the CNA tried to remove the resident from the situation. He stated he felt like the CNA's approach could have been better. He stated the cursing was not directed toward the resident. He stated after interviewing the CNA, the DON and Administrator felt like the CNA was remorseful and needed a break and could learn from the incident. He stated they re-educated the CNA and assigned the CNA to another location after her suspension . He stated he had not interpreted abuse in the incident, but he had believed the CNA needed to be re-educated and given a break and moved to another location to continue working. He stated they check with the residents where CNA was working and have not had any complaints or allegations made about her. He stated they have terminated others for abuse, and they did take all allegations seriously. He stated the CNA was suspended and the local police were notified, and he felt like the situation could have been handled differently and the CNA could have learned from the incident. He stated they wanted to do right by all their residents and would not have ever put them in any way of harm. In an interview on 04/08/2025 at 1:22 PM, the DON and the ADON stated as a group, which included the DON, ADON, Social Worker, and Administrator, they checked with all residents frequently, which included the residents on the hall where CNA A had been moved to work. They stated they have not had any negative responses from any of these resident regarding CNA. They stated these interviews were not documented but they had recently done safe surveys, which were documented, in accordance with another incident and there were no concerns. In an interview on 04/08/2025 at 2:42 PM, CNA B, stated she had worked in the facility for about five years. She stated she had been in-serviced many times and the last one was about a month ago she believed. She stated did not have any concern for any of her fell ow staff members being abusive towards any residents. She stated she had not had any specific concern concerns with CNA A being abusive or aggressive towards any residents and she had not ever witnessed anything like that from CNA A before herself. She stated she had not had any residents report any abusive or aggressive behavior to her regarding CNA A. She stated an example of abuse was screaming at a resident and she had witnessed abuse in this facility about four years ago. She stated she reported that abuse right after she had stopped it, and the facility took care of that immediately. She stated suspected abuse should be immediately reported to the ADM, which was the Abuse Coordinator. In an interview on 04/08/25 at 5:41 PM, the ADM and the DON stated prior to them reviewing the video footage, it was reported to them that a resident had defecated in a trashcan in the secure unit, and they were trying to identify who it was and that was why they reviewed the video footage. They stated they saw the incident that occurred with CNA A and Resident #1 on the video when they reviewed it and immediately began the investigation and reported it to state. They stated inconclusive meant that they were not able to identify abuse but that it was an inappropriate response from staff. They stated they trained CNA A on abuse and neglect so that CNA A would have a clear understanding of what abuse and neglect was because CNA A felt like she had defended and protected herself and the other residents. They stated the accusatory tone CNA A had used when she questioned Resident #1 as to why resident had moved the chair made Resident #1 become defensive and this was why they felt CNA A needed to be educated on abuse and neglect. Record review on progress notes completed by LVN C on 01/20/25 at 9:38 PM reflected I was in medication room and heard CNA A hollering my name, I went back to the dining room where she was, and CNA A stated that resident just slapped her in the face while I was moving a chair that she had moved. I asked resident what happened, and resident stated that she was telling me not to move stuff around, this is my house and I slapped her, and I'll do it again. I asked resident if we could go to her room to talk and she said no, I asked CNA to go tend to other resident's separating them. I asked resident if she was ok or hurt, I assessed her, but she said no but I am tired of people telling me what to do. I educated resident that she cannot slap or hit people when she get's upset or angry, that she can talk to me or go to her room until she gets her feelings calmed, that hitting is not the answer. Resident then went to sit in a chair at the back of dining room. No other resident's seen incident or was affected by resident's agitation. Resident is calm, sitting in back alone. I tried calling MD, no response, sent message, pending call back. I notified family notified DON. Record review of personnel file for suspension information/training reflected CNA A had been suspended for three days immediately on 01/21/25 with no pay. Record review of in-servicing for the past 3 months which included staff signatures and covered customer service (01/21/25), attitude (01/21/25), resident rights (01/21/25), abuse and neglect (01/21/25), name badges, beds made, resident clothing and belongings, phone use, answering call lights, attitudes (01/29/25), snacks, resident rights (02/09/25), abuse and neglect (02/09/25), abuse and neglect (03/13/25), resident rights (03/13/25), customer service (03/13/25), and attitudes (03/13/25) reflected CNA A was present for all and had been in-serviced covering all areas regarding attitudes, abuse and neglect, and resident rights except for the in-services held on 02/29/25. Review of the facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2001 and revised September 2022 reflected in part, 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. Policy Interpretation and Implementation - 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; 2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; b. neglect of residents; and/or c. theft, exploitation or misappropriation of resident property. 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems. 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements . Review of the facility policy Abuse, Neglect, Exploitation and Misappropriation Reporting and Investigating dated 2001 and revised September 2022 reflected in part, Policy Statement - All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation. Reporting Allegations to the Administrator and Authorities - 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. Investigating Allegations - 1. All allegations are thoroughly investigated. The administrator initiates investigations. 2. Investigations may be assigned to an individual trained in reviewing, investigating, and reporting such allegations. 3. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. a. Any evidence that may be needed for a criminal investigation is sealed, labeled, and protected from tampering or destruction. 4. The administrator is responsible for keeping the resident and his/her representative (sponsor) informed of the progress of the investigation. 5. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. Corrective Actions - 2. If the investigation reveals that the allegation(s) of abuse are founded, the employee(s) is terminated . Review of the facility policy Disciplinary Procedures dated 2010 reflected in part, It is the policy of this facility to employ a disciplinary system which is positive, equitable and directed toward the correction of conduct which does not conform to the policies and standards of the Company. Procedure: 1. General Provisions. a. Purpose. The purpose of discipline is to correct a deficiency in performance or conduct which does not conform to the policies and standards of the company. Discipline is to be administered in an objective, equitable and consistent manner. Discipline is to be invoked only after a thorough examination of the facts, which will include providing the employee an opportunity to explain his or her conduct. b. Documentation. All disciplinary action and the facts upon which such action is based will be maintained in an accurate written record. A copy of all records of disciplinary action will be maintained in the employee ' s personnel file. Written statements, using the Witness Statement Form or a blank sheet of paper may be obtained from all witnesses to conduct an investigation which may result in disciplinary action. c. Management Responsibilities. The management personnel in each office and facility are responsible for communicating to employees the policies, rules and expectations with which employees are to comply. Management personnel are also charged with ensuring that all policies and rules are fairly administered. All disciplinary action is to be conducted in a professional manner. The use of loud, abusive, or obscene language is not acceptable. Immediate Discharge. a. An employee may be immediately discharged without prior informal, verbal, or written counseling if the employee commits a serious offense such as are listed in b below. b. The following offenses are those for which immediate discharge may result. This list is not all-inclusive, and the Company reserves the right to discharge employees for other conduct which it deems to be serious in nature. l. Resident/patient abuse or neglect of resident/patient is duties directly related to the safety, health and/or physical or mental well-being of the resident/patient. 2. Violation of Resident's Rights. This was determined to be an IJ on 04/08/25 at 6:00 PM. The ADM and the DON were notified. The ADM was provided with the IJ template on 04/08/25 at 6:13 PM and a Plan of Removal was requested. The following Plan of Removal was submitted by the facility and was accepted on 04/09/25 at 10:40 AM and reflected the following: On 04/08/2025 an abbreviated survey was initiated. On 04/08/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: F600, the center failed to prevent CNA A from physically abusing Resident #1 when she shoved resident #1 in the right arm and in the back. F600-The center failed to prevent CNA A from physically abusing Resident #1 when she shoved resident #1 in the right arm and in the back. CNA A was placed on suspension pending termination on 4/8/2025 by the Administrator. Director of Operations conducted re-education on Abuse and Neglect including recognizing, responding, and reporting abuse and neglect with the Administrator and Director of Nursing on 4/8/2025. Administrator and Director of Nursing voiced understanding of the re-education to the Director of Operations and signed the re-education. Resident #1 was assessed for signs and symptoms of physical abuse by the Director of Nursing on 4/8/2025 with no negative findings. A progress note was charted on 4/8/2025. All residents that are able to be interviewed for any abuse and/or neglect event (no cognitive impairment) were interviewed by the Director of Nursing/Designee on 4/8/2025 with no negative findings identified. A progress note was charted for each resident on 4/8/2025. All residents with cognitive impairment/not inter-viewable were assessed by the Director of Nursing/Designee on 4/8/2025 for signs/symptoms of physical abuse with no negative findings. A progress note was charted for each resident on 4/8/2025. All staff were re-educated on abuse and neglect including recognizing, responding, and reporting abuse and neglect by the Administrator/Designee on 4/8/2025. Staff not present will be re-educated prior to the start of their next shift and this will be completed by 4/9/2025 (end of business day). Staff voiced understanding of the re-education to the Administrator/Designee and signed the re-education. The Medical Director of the center was notified of the immediate jeopardy event on 4/8/2025. The Medical Director had no recommendations. The findings of this event will be presented to the center Quality Assurance Committee. An ad hoc Quality Assurance Committee meeting will be conducted on 4/9/2025. The Administrator/Designee will monitor/review incident reports and do random resident interviews during the work week (Monday through Friday) to validate no resident abuse and/or neglect events have occurred. These audits will continue weekly for four weeks. Negative findings will be addressed at the time of discovery and presented to the center Quality Assurance Committee. Monitoring of the facility's Plan of Removal included the following: Record review of Resident #1's clinical records revealed the resident had been assessed by nursing after the incident on 01/21/25 and did not have any injuries. Record review of QAPI meeting conducted by facility in regard to immediate jeopardy event held on 04/09/25 at 11:45 AM and consisted of ADM, DON, CRN, and RDO, MD participated via telephone. Record review of in-servicing dated 04/08/25 conducted by RDO reflected ADM and DON were in-serviced on abuse and neglect and abuse, neglect, exploitation, or misappropriation - reporting and investigating policy. Record review on in-servicing dated 04/08/25 conducted by ADON reflected staff were in-serviced on attitude and attitude policy. Record review on in-servicing dated 04/08/25 conducted by ADON reflected staff were in-serviced on conduct and behavior and conduct and behavior policy. Record review on in-servicing dated 04/08/25 conducted by ADON reflected staff were in-serviced on reporting work burnout. Record review on in-servicing dated 04/08/25 conducted by ADON reflected staff were in-serviced on courtesy and courtesy policy. Record review on in-servicing dated 04/08/25 conducted by ADON reflected staff were in-serviced on resident rights and resident rights policy. Record review of staff interviews dated 04/08/25 reflected 3 resident interviews were conducted regarding abuse and neglect with no negative outcomes and residents all felt safe and comfortable with reporting harm if it had occurred. Record review of employee interviews dated 04/09/25 reflected employee interviews were conducted regarding abuse and neglect with no negative outcomes and staff all knew that they were required to report abuse immediately to the abuse coordinator. Record review of comparison of schedules worked and staff which were in-serviced signatures reflected all staff that have worked in the facility since immediate jeopardy was identified have been in-serviced appropriately according to facility plan of removal. Interviews were conducted on 04/09/25 from 1:20 PM to 1:25 PM and 1:45 PM to 2:29 PM with staff from various shifts. The staff included LVN A, CNA F, HSK, CNA C, LVN B, CNA D, and CK. All staff were able to identify: What abuse was and the different types of abuse. The staff understood how to recognize, respond, and report abuse. Observations and interviews with Resident's #2, #3, and #4 on 04/09/25 from 1:28 PM to 1:39 PM revealed they felt safe and had no concerns for abuse or neglect. In an interview on 04/09/25 at 4:38 PM, the ADM, DON, and ADON stated they had in-serviced all staff that have worked since the immediate jeopardy was called and staff would continue to be in-serviced and would be in-serviced prior to their shifts if they had not already been, on attitude, conduct and behavior, burnout, courtesy, resident rights, and abuse and neglect, which included recognizing, responding, and report abuse. They stated they were in-serviced over these things as well. They stated CNA A has been suspended and will be terminated as soon as she returned their call or tried to show up at work. They stated they had been trying to call CNA A and had not been able to get ahold of her. In an interview on 04/09/25 at 4:45 PM, the DON stated CNA A had returned her call and would be coming to the facility the next day to be terminated. The Administrator and DON were informed the Immediate Jeopardy was removed on 04/09/25 at 4:54 PM. On 04/08/25 at 6:00 PM, an IJ was identified. While the IJ was removed on 04/09/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for one (Hand Sink #1) of one hand sink in the kitchen reviewed. The facility failed to ensure the safe and sanitary operation of the solitary hand sink (Hand Sink #1) in the kitchen which resulted in the contaminated water from the hand sink coming out of the floor of the dishwasher area. This failure puts residents at risk for inadequate hand hygiene by staff, food borne illness and decreased quality of life. Findings included: An observation on 06/25/2024 at 6:40 AM revealed the hand sink, when used, the water came out of the floor drain in the dishwasher area adjacent to the hand sink. The water coming out of the floor drain after hand sink use was clear but had a strong foul odor. In an interview on 06/25/2024 at 6:41 AM, DIET AIDE F stated to turn the water and do not use the hand sink as it drained out of the floor drain in the dishwasher area. He stated the hand sink drain line had been backed up for a couple of weeks and their maintenance director would unclog it when he had time. He did not know the last time the maintenance director had to unclog the drain line. In an interview on 06/25/2024 at 6:44 AM, COOK G stated the drain line from the hand sink to the sewer line would back up if they used the hand sink which resulted in the water from the hand sink coming out of the floor drain. She said it had been that way for a couple of weeks. She said they recently remodeled the kitchen and when they put the hand sink in place, the drain started backing up. She reported the hand sink issue to the DM and used the other sinks in the kitchen to wash her hands when needed. In an interview on 06/25/24 at 10:15 AM, the DM stated the hand sink was an issue for a while but then a plumber snaked it and it worked again. She stated it must have backed up again and their maintenance director would just need to clear the drain line again. The kitchen floor was recently replaced and they recently moved the hand sink back into place. She stated maybe it messed up the pipes because the maintenance director fixed it again this morning and the water draining from the hand sink no longer came out of the floor drain in the dishwashing room. She stated the inability for staff to wash their hands at a designated sink put residents at risk of staff having poor hand hygiene and residents at risk for food borne illness due to contamination. She stated they just notify the maintenance director verbally of any maintenance needs in the kitchen and he fixed everything as needed. She said they do not have a maintenance log or other form of record keeping for maintenance requests from the kitchen. She stated she knew the two nursing stations had maintenance request books, but the kitchen did not use those books for logging their maintenance requests. She did not know why the kitchen did not have a maintenance log book. In an interview on 06/25/2024 at 2:30 PM, the MAINTENANCE DIRECTOR stated he had to snake the drain from the hand sink and it started draining normally. He stated the line can be clogged due to grease etc, and when needed, he cleaned out the line. He stated the DM notified him it was clogged this morning and then he unclogged it within a few hours. He stated if the hand sink in the kitchen was not operational, then the staff would have to use a sink not designated for hand washing to wash their hands. He stated this could put residents at risk for contaminated foods causing illness. In an interview on 06/26/24 at 11:30 AM, the ADMIN stated the MAINTENANCE DIRECTOR cleared the hand sink drain line yesterday and it was now fully operational. He stated the sink line should not have been clogged as it made the hand sink non-operational. He stated dietary staff would have to use a different sink until the hand sink was finished. He stated they may look into putting in a second hand sink, so that if one is not working they always have an extra. He stated not having an operational hand sink put residents at risk for food borne illness due to lack of hand hygiene. Review of Equipment Maintenance policy undated revealed a log of required maintenance will be kept to ensure maintenance requests are completed as required and timely.

Based on observation, interviews, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs in order attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one resident (Resident #13) of 6 residents reviewed for care plans. The facility failed to create a care plan addressing Resident #13's smoking at the facility. This failure placed smoking residents at risk for injury from burns and all the residents at the facility from fire caused by hazardous smoking behaviors. Findings included: Record Review of Resident #13's face sheet dated 06/25/24, revealed he was a [AGE] year-old individual who was admitted to the facility on [DATE]. His diagnoses included Hypertension, Atherosclerotic heart disease (Developing plaque in arterial walls), Shortness of breath, Congestive heart failure, Presence of automatic (implantable) cardiac defibrillator (Device to restore normal heartbeat), Dementia, Psychotic disturbance, Mood disturbance, Anxiety, Lack of coordination, Muscle wasting and Vascular dementia. Record Review of Resident #13's MDS assessment dated [DATE], reflected he had a BIMS score of 12, indicating moderate cognitive impairment The MDS indicated he was on oxygen therapy and was actively diagnosed of non-Alzheimer's dementia. Record Review of Resident #13's care plan dated 06/07/24 revealed there was no care plan addressing Resident #13's smoking at the facility. Record review of Resident #13's monthly Safe Smoking assessment dated [DATE] and 05/07/24 identified him as active smoker and stated Care Plan up to date or updated. Observation on 06/26/24 at 1:30 PM revealed Resident #13 and another resident were smoking cigarettes at the designated area for smoking, while CNA A supervised. During an interview on 06/26/24 at 12:30 PM, Resident #13 stated he smoked at the scheduled time and at a place designated for smoking at the facility. Resident #13 stated he collected the cigarettes and lighters from the staff at the nursing station and handed them over to them after the smoking was finished. During an interview on 06/26/24 at 2:00 PM, CNA A stated all the smoking residents' cigarette smoking materials were locked up at the nursing station and provided to them only at the scheduled smoking period. She stated, as per the ongoing practice , one of the staff members supervised them while they smoked. When the investigator asked her, where did she get the plan, she stated it was the usual practice at the facility. She said she did not look at the care plan in PCC. Interview on 06/26/24 at 2:30 PM with the DON revealed there was no MDS Coordinator working at the facility. The DON said the MDS was completed at the corporate office for all the residents, and it was the responsibility of the IDT to make sure the care plan was up-to-date. She stated a proper care plan for smoking was necessary to ensure the safety of the residents who smoked and other residents and staff at the facility, from fire hazards. She stated there were two residents at the facility who smoked, and they smoked under the supervision of a staff member. The DON stated individual assessments and care plans for smoking were necessary as the capabilities to carry out smoking safely varies from resident to resident. The DON stated she checked the care plans and confirmed that the other smoker at the facility had a care plan for smoking. However, Resident #13 did not have a care plan for smoking. During an interview at 3:45 PM, the ADM stated a person-centered care plan was important to achieve the set goals as it gave direction to the staff for implementation of tasks. He stated the care plan for smoking was essential to minimize fire hazards occurring from smoking and thus ensure safety of everyone at the facility. The ADM stated the primary responsible person for developing a care plan was the MDS coordinator. However, it was the responsibility of every individual in the IDT to make sure the safe smoking assessment was conducted periodically and a care plan for smoking was developed for the residents who smoked at the facility. Record review of in-service records revealed there were no in- services on smoking, between 04/01/24 and 06/26/24. Review of the facility's Care Plan, Comprehensive Person Centered policy, dated March 2022, revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 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. .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 . d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problems areas and conditions . 12. The interdisciplinary team reviews and updates the care plan: . . at least quarterly, in conjunction with the required quarterly MDS assessment Review of the facility's Smoking Policy-Residents policy, revised in August 2022, revealed: . 8. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. 9. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues

Based on interview, observations, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights, which included measurable objectives and time limits to meet a resident's medical, nursing, and mental, and psychosocial needs for 1 of 6 residents (Resident #1) reviewed for care plans. Resident #1's comprehensive care plan dated 05/02/2024, inaccurately reflected the resident was receiving a regular texture diet. These deficient practices could place residents at risk for not receiving proper care and services due to inaccurate care plans. The findings were: A record review of Resident #1's face sheet reflected Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of dysphagia (swallowing difficulties), Cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information and following instructions), Obesity (abnormal or excessive fat accumulation that presents a risk to health), and metabolic encephalopathy (a problem in the brain cause by a chemical imbalance in the blood). A record review of Resident #1's Quarterly MDS assessment, dated 04/26/2024, reflected Resident #1's BIMS score was 15 which indicated resident is cognitively intact. Resident #1's Quarterly MDS also reflected that Resident #1 was receiving a mechanically altered diet. A record review of Resident #1's Care Plan, dated 05/02/2024, reflected that Resident #1 was on regular texture diet. A record review of Resident #1's Physician Order, dated 06/05/2024, reflected Resident #1's mechanical soft texture diet start date was 09/22/2022 and was still a current order. A record review of Resident #1's Dietary Profile, dated 04/26/2024, reflected Resident #1's current texture of food was mechanical soft. In an interview with Resident #1 on 06/05/2024 at 11:10 am, Resident #1 stated she received a mechanical soft diet. An observation of Resident #1 on 06/05/2024 at 12:05pm, reflected Resident #1 was receiving a mechanical soft diet. In an interview with CNA A on 06/05/2024 at 11:15 am, CNA A stated that Resident #1 received a mechanical soft diet. In an interview with the DON on 06/05/2024 at 1:50pm, the DON stated that the MDS Coordinator was responsible for completing the care plan. The DON stated that the facility has been sharing an MDS Coordinator with their sister facility since March. The DON stated that she was aware that Resident #1 was receiving a mechanical soft diet but was not aware that Resident #1's care plan was inaccurate. The DON stated that if the care plan was inaccurate then that could cause a resident not to receive proper care. In an interview with the ADM on 06/05/2024 at 2:10pm, the ADM stated that it was the MDS Coordinator's responsibility for completing an accurate care plan for the resident in the facility. The ADM stated he was not aware that Resident #1's care plan did not reflect her mechanical soft diet. The ADM stated if the care plan was inaccurate then the resident could choke or not get the proper care needed. Review of the facility's Care Plan, Comprehensive Person Centered policy, date March 2022, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 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 d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problems areas and conditions .

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs for 2 of 8 residents (Residents #19 & #25) reviewed for care plans. 1.Resident #19's comprehensive care plan did not address the resident's use of oxygen. 2. The facility failed to develop a comprehensive care plan that addressed Resident #25's refusal of privacy bag and placement of drainage bag for s/p catheter; and the care plan failed to address his need for assistances when eating. These deficient practices could place residents at risk of receiving inadequate interventions that were not individualized to their care needs. The findings included: Review of Resident #19's face sheet, dated 04/26/23, revealed an [AGE] year-old male was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease with acute exacerbation (characterized by a worsening of the patients respiratory symptoms, dyspnea, cough and/or sputum, more than the usual day to day variations and requiring changes to their medication), chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), allergic rhinitis (allergic reaction that causes sneezing, congestion, itchy nose and sore throat), pneumonitis due to inhalation of other solids and liquids (your lungs have been inflamed by solids or liquid substances). Review of Resident #19's physician's orders, dated 03/17/22, revealed Resident #19 may use oxygen at 2 liters per minute per nasal canula - may take off if oxygen saturation above 92% and no shortness of breath noted - may increase to 4 liters prn. Review of Resident #19's MDS, dated [DATE] revealed Resident #19's BIMS score was 13 (out of 15) which indicated they were cognitively intact. Resident 19's MDS did reveal the use of oxygen. Review of Resident #19's Care Plan, dated 02/13/23, did not address the use of oxygen. Observation on 04/25/23 11:15 a.m. of Resident #19's room revealed Resident #19 using an oxygen machine inside of the room. Observation on 04/26/23 1:45 p.m. of Resident #19's room revealed Resident #19 using an oxygen machine inside of the room. Observation on 04/27/23 9:40 a.m. of Resident #19's room revealed Resident #19 using an oxygen machine inside of the room. Review of Resident #25's face sheet reflected a [AGE] year old male, admitted to the facility on [DATE] with diagnosis of Adjustment disorder with mixed anxiety and depressed mood (development of emotional or behavioral symptoms in response to identifiable stressors), Major Depressive disorder, recurrent Moderate (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with doing normal day to day activities), Obstructive and reflux uropathy (when your urine can not flow through your ureter due to obstruction), Other Schizophrenia (a disorder that affects the person's ability to think, feel and behave clearly.), and Muscle wasting and atrophy (loss of muscle mass and shrinking of muscles that make them hard to use). Review of Resident's #25's MDS dated [DATE] revealed that on section G question H, indicated Resident #25 was dependent in eating, section C 0600 revealed a Bims score of 02, Section H 0200 shows urinary catheter and H0400 shows occasional bowel incontinence. Observation of Resident #25 on 4/25/23 at 08:30 a.m. revealed he was walking in the hallway, a privacy bag was not observed covering his Foley bag. Attempted to speak with resident, his is response was garbled and not in response to the conversation. An observation on 4/25/2023 at 230 p.m. revealed Resident #25 was resting in bed. His Foley bag was observed lying on floor next to bed with no privacy cover noted. Resident was sleeping and did not awaken to his name. An observation on 4/26/2023 at 830 a.m. revealed Resident #25 was in bed with his Foley bag lying on the floor with no privacy cover in place. Resident was laying in bed with his cover over his face, no interview was attempted. An observation on 04/26/23 at 1230 p.m. Observed CNA A hang Foley bag off the floor and Resident #25 was observed putting the Foley bag back on the floor. CNA A was observed assisting Resident #25 with his meal secondary to contracture of both hands. An observation on 04/26/23 at 2:30 pm revealed Resident #25 was ambulating in hallway. A privacy cover was observed covering his Foley bag. Approached resident who walked away while attempt to interview him. An observation on 4/27/23 at 11:30 a.m. revealed Resident#25 was in his room ambulating. A privacy bag was not observed on his Foley bag An interview with CNA B on 4/25/23 at 08:45 revealed Resident #25 either refused or removed his privacy covering and would throw Foley bag on the floor when it was hung from the bed or a chair. CNA B stated Resident #25 required assistance with eating at each meal. An interview with LVN A on 4/25/20 at 09:45 revealed Resident #25 either refused or removed his privacy covering and refused to have Foley bag changed to a leg bag during the day. LVN AF stated Resident #25 also refused to hang the Foley on the bed or chair and would throw it on the floor. When asked if that was care planned, LVN A stated they were not sure, but stated it should be as the behavior put the resident at risk for infections and catheter displacement. LVN A stated Resident #25 required assistance with eating secondary to muscle contractures in his arms. They stated that Resident #25 was sometimes he was able to use a weighted spoon and other times he was unable to lift it. An interview with CNA A on 4/26/23 at 0830 revealed Resident #25 would remove the privacy bag when placed unless someone he liked put it on. CNA A stated Resident #25 refused to have the Foley bag hang from the bed frame or a chair and would remove the Foley bag it and lay it on the floor. The CNA stated Resident #25 required assistance with eating, some days he required cueing and on other days he required assistance with bringing the spoon to his mouth. An interview with LVN B on 4/26/23 at 10:30 a.m. revealed Resident #25 would allow her to place a privacy cover on his Foley bag but would often remove it shortly after. LVN A stated Resident #25 refused to leave the catheter bag hanging and would place it on the floor or sometimes lay it on the bed with him. LVN A stated Resident #25 did require assistance with eating and his ability to participate waxes and weans depending on his mood. Review of Resident # 25's care plan dated 3/16/2023 revealed it did not address that Resident #25 did not want the privacy cover on his Foley bag, that Resident #25 would not keep the bag hanging and would place the Foley bag on the floor. Resident #25's care plan did not reflect his needs for assistance with eating. An interview with the MDSC on 4/26/23 at 2 p.m. revealed Resident #25's behaviors were not captured on the MDS dated [DATE]. The MDSC stated it should be noted in the MDT or morning meeting and she would update the care plan as appropriate. The MDSC stated each discipline in the MDT had a section they were responsible for completing the care plan associated with the section of the MDS they completed. The MDSC stated that a resident that refused a Foley bag covering, proper placement and needed assistance with eating was at risk for medical complications and dignity issues if not care planned. The MDSC said nurses would know that a resident was receiving oxygen per physician's orders. Interview with the DON on 04/26/23 at 1:20 p.m. the DON stated baseline care plans are completed by the DON or RN and the comprehensive care plans are completed by the MDSC. She uses the information from the MDS, MDT, and morning meetings to ensure care plans reflected the care each resident is receiving. The DON said if a resident was receiving oxygen therapy it should be care planned. The DON stated a resident would not receive adequate care to meet their needs if they are not care planned for it. In a subsequent interview at 2:30 p.m. the DON stated residents with behaviors that are not compliant with Foley management and needed assistance with eating are at risk for medical complications and dignity issues and should be on the care plan. Interview with the ADM 4/27/23 at 10:30 a.m. revealed care plans are updated by the MDS nurse. The ADM stated the MDSC was supervised by the DON and Corporate MDSC. The ADM stated his/her expectation is that the care plan is updated from the MDS, MDT and morning meetings and the MDSC is responsible for that. The ADM's stated expectation is that someone who is not compliant with his Foley care and who needed assistance with eating should have a care plan that reflects those needs and preferences. The ADM stated if there were concerns that were not addressed on the care plan it could result in dignity issues and medical complications. The ADM stated the resident receiving oxygen should be care planned for oxygen therapy. The ADM said if a resident was not care planned for oxygen the facility would be out of compliance and the resident would not receive adequate care. The ADM stated the Corporate MDSC should have trained the facility's MDSC, but he was hired after the MDSC, so he was not sure of what training the MDSC received. A record of review of the facility's Care Plan Policy dated 02/13/2007, reflected, the facility will develop a comprehensive care plan for each resident that includes measurable short-term and long-term objectives and timetable to meet a residents medical, nursing and mental and psycho-social needs that are identified in the comprehensive assessment. A record of review of the facility's IDT Inservice Care Plan not dated, reflected What needs to be Care Planned: A record of review of the facility's IDT Inservice Care Plan not dated, stated What needs to be Care Planned: MDS: CAA's Psychotropic Medications (Anti-depressant, Hypnotic, Anti-Anxiety, Anti-Psychotic) Geri Chairs (comfort/positioning), Behaviors Medical Diagnosis Allergies Restraints Foley Catheters Feeding Tubes ADL's , even if they do not trigger on the CAA's Quality Measures ACTIVITIES: Residents likes/dislikes/preferences Residents Activities /preferences Update anytime there is a change Dietary Diets (ensure all restrictions are addressed) Update anytime there is a change SOCIAL SERVICES Code Status Discharge planning Psych Services Update anytime there is a change TREATMENT NURSE All wounds on the wound report Make sure to update with any changes and resolve out once wound heals DON/ADON Acute Care plan related to incidents (bruises, falls, new orders related to the incidents) Make sure the intervention s are updated Safety Devices (hipsters, bolsters, alarms, anti-tippers, anti- roll back, wander guards) Infections (acute care plan) Weight loss Review and resolve when needed. The care plan needs to be resident centered. Discuss with the residents their preferences. Make sure their preferences are in the care plan.

Based on interview and record review, the facility failed to ensure comprehensive assessments were completed within 14 calendar days after admission as required for two (Resident #182 and Resident #84) of six residents reviewed for comprehensive assessments. 1. Resident #182 admitted on [DATE] and the facility did not have a completed admission/comprehensive MDS assessment within 14 days following admission to the facility. 2. Resident #84 admitted on [DATE] and the facility did not have a completed admission/comprehensive MDS assessment within 14 days following admission to the facility. This failure could result in newly admitted residents not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Findings included: Review of Resident #182's face sheet on 04/26/23 reflected the resident was a [AGE] year-old female and was admitted to the facility on [DATE]. The diagnoses included Hyperlipidemia (excess fat in the blood), Headache, Schizophrenia, Chronic Kidney Disease, Systemic Lupus Erythematosus (an autoimmune disease in which the immune system attacks its own tissues) and Hypotension (low blood pressure). Review of Resident #182's MDS assessment summary screen in the EHR on 04/26/23 revealed the resident's admission/comprehensive MDS assessment was still in progress with ARD date 04/13/23. Review of Resident #84's face sheet on 04/26/23 reflected the resident was an [AGE] year-old female and was admitted to the facility on [DATE]. The diagnoses included Altered Mental Status, Dementia, Psychotic disturbance, Mood Disturbance, Anxiety, Atrial Fibrillation (irregular rapid heart rhythm), Chronic Kidney Disease, Heart Failure, Hypertension, Bradycardia (lower heart rate), and Edema (swelling). Review of Resident #84's MDS assessment summary screen in the EHR on 04/26/23 revealed the resident's admission/comprehensive MDS assessment was still in progress with ARD date 04/17/23. During an interview with the MDSC on 04/26/23 at 2:00 PM, she stated she worked at the facility as the MDSC since 02/01/22. She said members of the MDT were responsible for the MDS assessments and her role was compiling the information provided. The MDSC stated the process was still in progress for Residents #182 and Resident #84 and waiting for that information from MDT. The MDSC stated the initial MDS assessment must be completed in 14 days and the quarterly assessment should be done every 3 months. She said non completion of comprehensive assessment on time would affect the effectiveness of the care plan. The MDSC stated she had completed a training on MDS at the beginning of her job. During an interview with the DON on 04/26/23 at 12:00 PM, she stated the MDS assessment was the responsibility of the MDSC. She stated completing the MDS assessments within 14 days of admission was important because nursing staff needed to know how to care for the residents and the care plan was developed with the information from MDS. The DON stated the MDSC had received MDS training from corporate MDSC. During an interview on 04/27/23 at 11:49 AM, the ADM stated the MDSC was responsible for the MDS assessments and the MDSC was supervised by the DON and the Corporate MDSC. When asked about the trainings that was provided to MDSC, ADM stated the Corporate MDSC should have trained the facility's MDSC, but he was hired after the MDSC, so he was not sure of what training the MDSC received. When the investigator asked about the monitoring at the facility for efficiency, the ADM stated the issues were discussed daily in the morning meetings, also issues were reviewed during QAPI if they were brought to their attention. The ADM stated the deficiencies if any in administration and nursing care would be addressed with training and education and in extreme situations with disciplinary actions. The ADM stated delayed MDS data submission would affect quality of care due to ab insufficient care plan, as the information from the MDS was important in developing care plans. Record review of the facility's document New MDS Nurse Training dated 02/01/23 reflected, on 03/01/22 the MDSC received training on various aspects of the MDS. According to 'The Assessment Schedule for the RAI on website: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/nursinghomequalityinits/downloads/mds20rai1202ch2.pdf , revised in December,2022 and accessed on 05/01/2023 revealed: .The timing requirements for a comprehensive assessment apply to both completion of the MDS (R2b) and the completion of the RAPs (VB2). For example, an Admission assessment must be completed within 14 days of admission. This means that both the MDS and the RAPs (R2b and VB2 dates) must be completed by day 14 . .Admission Assessments: The admission assessment is a comprehensive assessment for a new resident that must be completed within 14 calendar days of admission to the facility if: o this is the resident's first stay, o the resident has just returned to the facility after being discharged prior to the completion of the initial assessment, or o the resident has just returned to the facility after being discharged as return not anticipated. The 14-day calculation includes weekends. When calculating when the RAI is due, the day of admission is counted as Day 1. For example, if a resident is admitted at 8:30 a.m. on Wednesday. (Day 1), a completed RAI is required by the end of the day Tuesday (Day 14), 13 days after admission. If a resident dies or is discharged within 14 days of admission, then whatever portions of the RAI that have been completed must be maintained in the resident's discharge record.1 In closing the record, the facility may wish to note why the RAI was not completed

Based on observation, interviews, and record reviews the facility failed to ensure the resident environment remained free of accidents and hazards as possible for two of five (Resident #1 and Resident #2) Residents and three of three housekeepers ( Housekeeper A, Housekeeper B and Housekeeping Supervisor C) reviewed for accidents and hazards. A. Housekeeper A walked to west side of the facility and left the housekeeping cart which contained chemicals on the east wing unlocked and unattended. Housekeeper A left the housekeeping cart which contained chemicals unlocked and unattended when cleaning in the tv area of the secure unit. B. Housekeeper B failed to close the compartment door which contained chemical and left the cart unattended. C. Housekeeping Supervisor failed to lock the housekeeping cart which contained chemicals and left the cart unattended. These failures could place residents at risk of injuries, illness, and hospitalization . The findings included: A. Review of Resident #1's face sheet dated 03/09/2022 reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses: Alzheimer's Disease ( a progressive disease that destroys memory and other important mental functions), Unspecified Dementia with Behavioral Disturbance (mental disorder in which a person loses the ability to think, remember, learn, make decisions and solve problems) and Type 2 Diabetes Mellitus with [CONDITION(S)] ( occurs when a person's blood sugar elevates to potentially dangerous levels that require medical treatment). Review of Resident #1's Quarterly MDS dated [DATE] reflected Resident had a BIMS score of 4 indicating resident cognition is severely impaired. Resident did not require any device when ambulating. Resident usually understands others (misses some part intention of message) and sometimes makes self-understood (ability is limited making concrete request). Review of Resident #1's Comprehensive Care Plan dated 12/30/2022 reflected Resident had impaired cognitive function/ dementia or impaired thought process related to dementia, impaired decision-making ability. Resident was unaware of safety needs. Resident was assessed with a communication problem related to confusion/ disorientation. Resident was elopement risk/wanderer. Disoriented to place, impaired safety awareness. Diagnosis of Dementia with Behavior Disturbance. Resident resides on secure unit. Identify pattern of wandering: purposeful, aimless, or escapist. Review of Resident #2's face sheet dated 03/09/2022 reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of : Vascular Dementia with behavioral disturbance ( caused by brain damage from impaired blood flow to your brain), essential hypertension ( high blood pressure), and [CONDITION(S)] ( a group of lung diseases that block airflow and make it difficult to breathe). Review of Resident #1's MDS dated [DATE] reflected resident had a BIMS score of 0 indicating his cognition is severely impaired. Resident is usually understood and usually understands. He exhibits the behavior of wandering. Resident ambulates with assistance of a walker. Review of Resident #1's Comprehensive Care Plan dated 12/26/2021 reflected resident had asthma. Resident had impaired cognitive function/ dementia or impaired thought process related to dementia. Resident wandered around the unit and is at risk attempting to elope related to diagnosis of dementia, poor safety awareness and BIMS of 0 (indicated his cognition is severely impaired). Observation on 03/09/2022 at 8:50 AM revealed Housekeeper A at the end of the east wing with a housekeeping cart. Housekeeper A walked away from her housekeeping cart end of east wing. with chemicals (All-purpose cleaner, disinfectant without the spray top on the plastic bottle, tub/tile cleaner, cream cleanser, air freshener, acid bowl cleaner, waste and odor degrader) in an unlocked compartment. The housekeeper walked to the west wing and returned to her housekeeping cart at 9:10 AM. In an interview on 03/09/2022 at 9:10 AM Housekeeper A stated she did not have a key until today for the housekeeping cart. She stated the lock was broken on the cart where chemicals are in the cart. She stated the chemicals are to be locked. She stated she was away from her cart and went to talk to her supervisor at the other end of the hall. She stated she had been in serviced on keeping chemicals locked. She also stated she was not to leave her housekeeping cart unattended when it was unlocked. She stated she never thought about if a resident could get the chemicals from her cart. She stated if a resident drank the chemicals she did not know what would happen to the resident. She stated she thought the resident may become sick and could die. She stated she reported the lock was broken to the maintenance supervisor and the housekeeping supervisor last month. She did not remember what the housekeeping supervisor or the maintenance supervisor said when she reported the broken lock to them. In an interview on 03/09/2022 at 9:18 AM Housekeeping Supervisor C stated her housekeeping cart locked and she was not aware the other two housekeeping carts did not lock until today. She stated there had not been an issue with the cart not being locked. If the housekeeper was on the secure unit, she can could watch the housekeeping cart and no resident would attempt to go near the cart. She stated she was responsible for monitoring housekeeping carts, but it was difficult on the days she worked as a housekeeper and had rooms to clean. In an interview on 03/09/2022 at 9:24 AM Maintenance Supervisor D stated no one had informed him the compartment lock does not work. He stated this was the compartment where chemicals were to be locked. He stated no one had reported anything to him. Today was first time he had heard the locks on the housekeeping cart does not work. He stated staff will verbally report to him when something needed to be repaired in the facility. Observation on 03/09/2022 at 9:28-9:45 AM Housekeeper A was on secure unit mopping the tv area and her housekeeping cart which contained chemicals was unlocked and the compartment door was almost half opened. Resident #1 was standing at the housekeeping cart and pulling on the top of the cart attempting to move it. Resident #1 was standing in front of the opened compartment door where the chemicals were stored. Housekeeper A had her back turned to the housekeeping cart and the housekeeping cart was approximately 23 feet from the housekeeper A. The unlocked housekeeping cart was in a hall past the nurses desk and past the opening to enter the tv area. Resident #1 walked away from the cart and Resident #2 walked toward the cart and was touching the compartment door where the chemicals were located. Resident #2 walked away when CNA D asked him to go with her to the table. In an interview on 03/09/2022 at 9:47 AM Housekeeper A stated she could not see the housekeeping cart from where she was standing in the tv area. She stated she did not see any residents approach the housekeeping cart. B) Observation on 03/09/2022 at 9:50 AM Housekeeper B was in the dining room cleaning and her housekeeping cart was in the doorway leading into the dining room and partially in the hall. The door to the locked compartment was almost half opened The compartment where chemicals (All-purpose cleaner, 2- spray bottles of disinfectant, tub/tile cleaner, cream cleanser, air freshener, acid bowl cleaner, 2- waste and odor degrader) were stored was unlocked. The Housekeeper had her back turned toward the housekeeping cart and was finishing mopping in the dining room. In an interview on 03/09/2022 at 9:53 AM Housekeeper B stated the housekeeping carts she had been using for a year had never locked. She stated she reported this to Housekeeping Supervisor C and the Housekeeping Supervisor C stated she would check on it. She stated she had reported it approximately 5 times in the past 4 months. She stated she knew the compartment was to be locked where chemicals were stored, and she was not to leave the cart unattended. She stated they had received in-service from the Housekeeping Supervisor on locking cart and not leave the cart unattended. She did not recall the last time she had received in-service on locking the housekeeping cart. She also stated the residents did have access to the chemicals and if they drank any chemical it could cause problems with their stomach and throat such as burning, and the resident may need hospitalization . She stated if it was a certain chemical a resident could possibly die. C) Observation on 03/09/2022 at 10:00 AM Housekeeping Supervisor was in room 204 mopping and the housekeeping cart was unlocked in the hallway near room 204. Observed the compartment was unlocked in the housekeeping cart where chemicals (all-purpose cleaner, spray bottle of disinfectant, tub/tile cleaner, cream cleanser, acid bowl cleaner, waste, and odor degrader) were located . The Housekeeping Supervisor had a key to the cart, and it did lock. She stated she was mopping in a resident's room and was near the cart. She also stated she had her back turned to the housekeeping cart when she was mopping. She also stated she had in serviced her staff on locking chemicals and not leaving their cart unattended. She stated she did not have this on paper she verbally informed the housekeepers. In an interview on 03/09/2022 at 10:03 AM the Housekeeping Supervisor C stated she could see the cart from where she was standing in resident room #204. She stated she was mopping and was facing the window of the room at one time while mopping. She also stated her back would have been toward the housekeeping cart when she was facing the window. She stated the housekeeping cart was not to be left unattended when the compartment where chemicals were stored was unlocked. In an interview on 03/09/2022 at 11: 45 AM the Administrator stated all chemicals were to be locked and secured in the housekeeping carts. He stated the housekeepers was expected not to leave their housekeeping carts unattended. This was not acceptable. He stated a resident had potential to drink chemical and could die or become severely physically ill. He also stated it was the housekeeping supervisor responsibility to check the housekeeping carts for any malfunction on the carts and report it immediately to maintenance or to him. Record Review of Safety Data Sheets of All-Purpose Cleaner dated 11/11/2013 reflected page 2 and page 4 was not given at time of exit. The all-purpose cleaner reflected on page 1 causes serious eye irritation, harmful if swallowed and harmful if absorbed through the skin. May cause skin irritation. If swallowed call physician or poison control center. Record Review of Safety Data Sheets of cream cleanser dated 11/13/2013 reflected page 2 and page 4 was not given at time of exit. The cream cleanser reflected on page 1 causes skin irritation, harmful if swallowed and causes serious eye irritation. If skin irritation occurs, get medical attention. If swallowed call a poison center or doctor. Record Review of Safety Data Sheets of disinfectant spray dated 07/30/2013 reflected ingestion: possible gastrointestinal irritation or disturbance. Inhalation: possible coughing, drowsiness, or loss of consciousness. Will cause eye and skin irritation upon exposure. Keep out of reach of children. Record Review of Safety Data Sheets of waste and odor degrader dated 11/143/2013 reflected page 2 was not provided at time of exit. The waste and odor degrader reflected on page 1 may be harmful if swallowed or inhaled. If skin irritation occurs, get medical attention. Call a poison center or doctor if feel unwell. Record Review of Safety Data Sheets of Neutral Disinfectant Cleaner dated 11/13/2013 reflected pages 2, 4 and 6 was not provided at time of exit. The neutral disinfectant cleaner on page 1 reflected May be harmful if inhaled, harmful if swallowed, causes eye irritation and mild skin irritation. If swallowed call poison control center or doctor. If skin irritation occurs get medical attention. If eye irritation persists, get medical attention. Record Review of Safety Data Sheets of Air Freshener dated 11/13/2013 reflected page 2 was not provided at time of exit. The air freshener on page 1 reflected causes serious eye irritation, may cause an allergic skin reaction and harmful if swallowed. If eye irritation persists, get medical attention. If skin irritation or rash occurs, seek medical advice/ attention. If swallowed call poison control or doctor. Record Review of Safety Data Sheets of Acid Bowl Cleaner revised on 11/01/2013 reflected pages 2 and 4 was not provided at time of exit. The acid bowl cleaner on page 1 reflected causes serious skin [CONDITION(S)] and eye damage. May cause respiratory irritation. Do not breathe dust /fume/ gas/ mist/ vapors/ spray. If inhaled remove person to fresh air and keep at rest in a position comfortable for breathing. Immediately call poison control or doctor. Store locked up. The facility policy on housekeeping carts was not provided at time of exit.

Based on observation, interviews, and record reviews the facility failed to prepare and serve food in accordance with professional standards for food service safety for one of one kitchen, reviewed for food store, prepare serve sanitation. The facility failed to ensure the Dietary Cook A wore a hair net, beard net and properly use hand sanitation when rolling silverware into napkins. This failure placed residents who were served from the kitchen at risk for health complications and foodborne illnesses. The findings included: Observation on 03/09/2022 at 10:55 AM revealed Dietary Cook A was wearing a baseball cap. The baseball cap did not cover the bottom and sides of his hair. There were approximately 7 inches of hair below the baseball cap. The Dietary Cook was not wearing a beard guard. His beard was approximately 8 inches long. In an interview on 03/09/2022 at 10:58 AM the dietary cook A stated all his hair was required to be covered including his beard when he was in the kitchen. He also stated there were beard nets and his beard was also to be covered. He stated he had been in serviced on covering all his hair including his beard. He did not know the last time he had the in-service . He also stated it was a possibility if hair was not covered it could fall into resident's food. Observation on 03/09/2022 at 11:01 AM dietary cook A donned ( put gloves on hands) a glove without washing his hands and began to roll silverware into napkins (he rolled approximately 10). He picked up a napkin from on the floor while wearing the same gloves and his fingers to his right hand touched the floor. He threw the napkin away and his right hand touched the top of the garbage barrel. Dietary cook A continued to roll the silverware in a napkin and touched the tines of 4 forks. Observation on 03/09/2022 between 11:05- 11:25 AM dietary cook did not cover his hair with a hair net or beard net. In an interview on 03/09/2022 at 11:08 AM dietary cook A stated he did not change his gloves when his hand touched the floor when picked up the napkin. He stated he did touch the top of the forks (pointed to the tines of the fork). He stated I will take the ones I have rolled and wash them. These two are the only ones I put in napkins with dirty gloves. Observation on 03/09/2022 at 11:10 AM revealed dietary cook A did not donn a hair net or beard net when surveyor exited the kitchen. In an interview on 03/09/2022 at 11:30 AM the Administrator stated all dietary staff and any staff entering the kitchen was required to wear a hair net or beard net. Hair can fall into resident's food and this was contamination of food. The administrator stated he was bald, and he wore a hair net when he went into the kitchen. He stated he expected anyone entering the kitchen to cover their hair and if anyone had a beard to cover the beard. He stated it was the dietary's manger responsibility to check hair and beard nets. Review of the facility Policy on Infection Control dated 2012 from the Dietary Service Policy and Procedure Manual reflected 1. Personal cleanliness is required in sanitary food preparation: b. Clean hair is required. It is to be totally covered with an effective hair restraint. Facial hair is to be closely trimmed and is to be covered with a hair restraint. 2. Careful hand washing by personnel will be done in the following situations: b. Between handling dirty dishes, boxes, or equipment and handling clean food or utensils

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for two of six staff (CMA A and LVN B) reviewed for infection control. A. The facility failed to ensure CMA A followed the facilities COVID-19 protocol of wearing gown appropriately before entering Resident #2's room who was on the warm zone (COVID-unknown) unit. B. The facility failed to ensure LVN B followed the facilities COVID-19 protocol of wearing gown appropriately before entering Resident #1's room, who was on the hot zone (COVID-positive) unit. These failures could place residents at risk of transmission and/or spread of infection. Findings include: A). Observation on 03/09/2022 at 10:06 AM revealed CMA A entered room # 212 on the warm zone ( Resident return from hospital had potential of being exposed to COVID- 19) without her gown being tied in the back. The gown on the right side was hanging off the shoulder of CMA A. She was administering medications and part of her clothing on the right side touched the resident arm/ hand. Prior to exiting room [ROOM NUMBER] CMA A doffed ( removed gown from the staff body) the gown in the container located in room [ROOM NUMBER]. When she doffed the gown, it was not tied in the back. There were posters outside of each resident's room on sequence for putting on personal protective equipment gown, mask or respirator, goggles or face shield and gloves. Gown: fully cover torso from neck to knees, arms to end of wrists, and [NAME] around the back. Fasten in back of neck and waist. The other posters beside each rom how to safely remove personal protective equipment, contact precautions and droplet precautions. In an interview on 03/09/2022 at 10:15 AM CMA A stated she thought her gown was tied and it probably came loose. She stated if a gown comes untied it was very likely a person would feel it falling off their body. She stated she had been in serviced on wearing PPE and tie the gown when entering a resident room. She also stated there were posters on the side of each room explaining how to wear a gown and it did show how to tie the gown. She stated she did not know if her clothes touched the resident in room [ROOM NUMBER]. B). Observation on 03/09/2022 at 10:20 AM LVN B entered room [ROOM NUMBER] on the hot zone (Residents with COVID) without his gown being tied in the back and the gown was hanging off his left shoulder. LVN B closed the door. When he exited room [ROOM NUMBER] his gown was not tied and was hanging off his left shoulder. LVN B pulled gown over his shoulder but did not tie the gown. There were posters outside of each resident's room on sequence for putting on personal protective equipment gown, mask or respirator, goggles or face shield and gloves. Gown: fully cover torso from neck to knees, arms to end of wrists, and [NAME] around the back. Fasten in back of neck and waist. The other posters beside each room on how to safely remove personal protective equipment, contact precautions and droplet precautions. In an interview on 03/09/2022 at 10:25 AM LVN B stated he did not tie his gown when entering room [ROOM NUMBER]. He stated there were posters on the wall beside each room demonstrating how to appropriately wear PPE. He stated his gown was not tied. He also stated he had been in serviced to tie his gown when entering residents' room. He stated he knew his gown was required to be tied. He stated he was entering the resident room to check on the resident. In an interview on 03/09/2022 at 3:50 PM the DON C stated all staff were expected to tie their gowns when entering a resident's room. She stated if the gown was not tied according to infection control standard, a resident or staff could possibly contract COVID from staff clothing. She also stated the facility had a recent infection control meeting for all the staff in the facility explaining the proper use of all PPE and hand hygiene. She stated there were examples of how to wear gowns appropriately on a poster outside of each resident's room on hot and warm zone. She stated it was the infection control preventionist responsibility to monitor proper use of PPE and provide in-services. She stated the staff on the hot zone was verbally given in-services. She also stated the reason verbal in-services was given due to not wanting the staff on the hot zone to touch the forms and other staff not working the hot zone would also be touching the same forms. In an interview on 03/09/2022 at 4:15 PM the Administrator stated all staff are to follow infection control guidelines including wearing gowns. He stated all gowns were to be tied by protocol. He stated there was an example of how to tie a gown on a poster outside of each resident room on the warm and hot zone. Record Review of Inservice on Infection Control dated 03/03/2022 reflected donning and doffing PPE was discussed during in-service. Please be sure that you are properly donning and doffing PPE- there are signs posted in both warm and hot zones if you are unsure- READ before you put on your PPE. CMA A attended the in-service and LVN B was verbally given the in-service by the ADON D Record Review of Facility Policy on Infection Control not dated reflected: 1. Gowns and protective apparel are worn to provide barrier protection and reduce the opportunity for transmission of microorganisms. Gowns are worn to prevent contamination of clothing and to protect the skin of personnel from blood and body fluid exposures. 2. Gowns are also worn by personnel during the care of patients infected with epidemiologically important microorganisms to reduce the opportunity for transmission pathogens from residents or items in their environment to other residents or environments; when goes are worn for this purpose, they are removed before the personnel leave the resident's environment.

Based on interviews, record reviews, document review, and facility policy review, it was determined that the facility failed to report allegations of verbal, sexual, and physical abuse, and staff to resident abuse to the administrator and to the state survey agency. This affected 2 (Resident #31 and Resident #25) of 3 residents reviewed for abuse. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 (Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of K. The IJ began on 04/21/2020 when Resident #31 walked up to another resident that morning and kissed that resident on the mouth and the incident was not reported to the state agency. The Administrator and DON were notified of the IJ on 02/05/2022 at 9:30 AM and provided the IJ Template at 9:54 AM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 02/11/2022 at 6:20 PM. The IJ was removed on 02/13/2022 at 10:25 AM after the survey team performed onsite verification that the Removal Plans had been implemented. Noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that was not immediate jeopardy for F609. Findings included: A review of the facility policy titled, Abuse and Neglect, revised 08/28/2017, revealed, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart .Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or other volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals .It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse .D. Identification. The facility will identify and investigate events that may constitute abuse/neglect .1. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services .3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility administrator or designee will report the allegation to the Texas Department of Aging and Disability (DADS). A. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. 1. A review of the face sheet revealed the facility admitted Resident #31 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the discharge Minimum Data Set (MDS), dated [DATE], indicated that Resident #31 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated severe cognitive impairment. Resident #31 required supervision with set-up assistance with bed mobility, dressing, and toileting. Resident #31 required limited assistance of one person with eating. A review of the care plan, initiated on 08/01/2021, revealed the resident had the potential to exhibit behaviors such as physical aggression, hollering and cussing, and grabbing staff and other residents. Further review revealed Resident #31 had been exposing themself to female residents, and staff were to re-direct resident as needed for behaviors. A review of nursing progress notes between April 2021 and January 2021 revealed the following: - On 07/14/2021 at 6:05 PM: Resident #31 walked up to another resident and kissed the resident on the mouth that morning. The other resident did not resist. The residents were separated at the time. Resident #31 had been very moody during the shift and was quick to curse at staff when the resident asked for something and did not get the response the resident wanted. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 07/27/2021 at 3:21 PM: Resident #31 had been placing resident's hands high up on a female resident's thigh and kissing other residents. Staff informed the residents that those behaviors weren't allowed but the residents continued and had to be physically separated. The residents were remined to keep their hands to themselves, but they resumed their activity after a few minutes. The staff re-enforced the rules. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 07/30/2021 at 2:27 PM: Resident #31 was observed kissing one of the female residents on the lips and both residents were separated and reminded that this type of activity was not allowed. The residents voiced understanding but then Resident #31 tried to lead a female resident to the resident's room. Staff informed the residents that was not allowed. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 08/07/2021 at 8:53 PM: Resident #31 was observed trying to hold hands and kiss female resident on the lips and the residents were redirected. Resident stated, Well it wasn't a kiss really and walked off. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 08/27/2021 at 2:54 PM: Resident #31 was observed putting their hand on a female resident's breast and the resident was told that type of behavior was not allowed. The resident got up and went to the resident's room. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 08/30/2021 at 3:02 AM: Resident #31 noted to have sexual behaviors this shift that required redirection. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 09/01/2021 at 2:55 PM: Resident #31 recently had an increase in sexual advances to the female residents and exposing themselves. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 10/09/2021 at 5:44 PM: Resident #31 had the hand of one of the female residents up in the resident's private area. The residents were redirected. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 10/13/2021 at 2:56 PM: Resident #31 was caught fondling the breast of one of the female residents. The resident was redirected. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 10/15/2021 at 2:35 PM: Resident #31 became combative with staff and staff hugged the resident to stop the resident from hitting them. Staff unhugged the resident and the resident became physically aggressive and grabbed the staff member's arm and scratched them. Staff attempted to redirect the resident to calm the resident down, but Resident #31 became verbally combative. The resident was finally able to be redirected. The note did not indicate that physician, family, or Administrator were notified. - On 10/25/2021 at 1:02 PM: Resident #31 was observed kissing on female residents, touching female residents' breasts, and encouraging them to touch the resident's private area. The resident was redirected. The note indicated a fax was sent to the physician. - On 12/05/2021 at 10:44 AM: Resident #31 continued to encourage female residents to touch the resident's private area and kiss them on the lips. The resident was redirected. Further review revealed the family and DON were notified but there was no documentation that the physician was notified. - On 12/05/2021 at 11:55 PM: Resident #31 was observed grabbing a female resident's right arm in an aggressive manner and told the female resident to shut up which scared the female resident. The staff explained that behavior was no appropriate. The resident was later observed kissing another female resident. The staff explained to the resident that it was inappropriate and educated the resident on the rules of keeping resident hands to themselves. The resident indicated they understood. Further review revealed the family and physician were notified. - On 01/01/2022 at 4:04 PM: Resident #31 gave a female resident a hug and tried to kiss the female resident and put the female resident's hand on the resident's private parts. Staff reminded the resident that type of activity was not allowed. The note indicated the resident had been exhibiting verbal aggression towards staff. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 01/02/2022 at 11:55 AM: Resident #31 was making sexual advances to a female resident again and continued to display verbal aggression when redirected. Further review revealed a fax was sent to the physician, but there was no documentation the family was notified. 2. A review of the face sheet revealed the facility admitted Resident #25 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the discharge Minimum Data Set (MDS), dated [DATE], indicated that Resident #25 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated severe cognitive impairment. Resident #25 required extensive assistance of two staff with bed mobility, dressing, and toileting. Resident #25 required limited assistance of one person with eating. A review of the care plan, initiated on 08/01/2021, revealed the resident had the potential to exhibit behaviors such a physical aggression, Further review revealed Resident #25 had sexually inappropriate behaviors. Staff were to explain to the resident acceptable sexual expressions, listen and talk to resident, and see if resident would explain why they did the behavior. A review of nursing progress notes between July 2021 and January 2021 revealed the following: - On 07/02/2021 2:20 PM: Staff heard a loud thud and overheard the CNA tell Resident #25 not to hit another resident like that. The CNA reported that the resident hit another resident in the chest. When the resident was asked about the incident, the resident made a threat towards staff. The residents were separated. Staff assessed the resident who was hit but no bruise was visible on the resident's chest. Staff were unable to redirect the resident. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 07/02/2021 at 2:54 PM: Staff observed Resident #25 in his wheelchair in the hallway with their penis pulled out. Staff explained to the resident that was inappropriate behavior. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 07/08/2021 at 11:21 PM: Overhead Resident #25 tell their roommate that the resident would beat them up. Staff redirected the resident successfully and the resident apologized to the roommate. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 08/03/2021 at 7:45 AM: Resident #25 was observed with the resident's hand on a female resident's leg and with the resident's privates out in other hand. The resident was redirected multiple times. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 09/21/2021 at 2:52 PM: Staff overheard Resident #25 tell one of the female residents that the resident was going to get it out and work on it. Staff redirected the resident to the resident's room. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 01/20/2022 at 6:53 AM: Staff observed Resident #25 hollering at residents and then staff observed fluid all over Resident #25 and saw another resident holding an empty cup in their hand as they walked towards their room. Further review revealed the family was notified but there was no documentation that the physician was notified. An interview on 02/03/2022 at 6:10 PM with LVN B revealed the victims of potential sexual abuse should have been assessed for injuries and notifications made to the state agency. An interview on 02/05/2022 at 9:01 AM with the ADON revealed any incidents that were suspected abuse should be reported to the DON and administrator. A telephone interview on 02/09/2022 at 5:37 PM with Director of nursing (DON) revealed that if there was a resident-to-resident incident it should only be reported to the state agency if there was an injury. DON also stated that an investigation would determine if an incident needed to be reported and felt that two hours was sufficient time to determine if an incident was abuse and needed to be reported. An interview on 02/06/2022 at 1:10 PM with Administrator revealed he had not reported any of the incidents with Resident #31 and Resident #25 to the state agency and that he was not aware of any of the incidents. The Administrator stated he agreed all the incidents documented in progress notes for Resident #31 and Resident #25 should have been reported to him and to the state agency. Removal Plan: 1. Staff have been educated on Reporting any abuse allegations, in particular to verbal, sexual and physical abuse, injury of unknown origin, staff to resident abuse and for residents identified in the IJ template. They have been educated on reporting all allegations to the abuse coordinator and/or the co-coordinator. These reports are to be done immediately by the person who witnesses abuse. This was completed by 2-10- by Administrator, DON, Nurse consultant, CEO, COO. 2. Nurse interviews for the secure unit were completed by the Administrator, COO and CEO to identify any further incidents that had not been reported on 2-5-22. None were identified. Any potential residents that are affected will have their family and physician notified, at the time of the incident by the charge nurse on duty, this will also be reported to the abuse coordinator which will also report to the appropriate state agencies and authorities. This is current policy and will be monitored by the DON or designee, during the morning meeting. All 5 other male resident's MDSs has been reviewed and no other male residents have been identified as having sexual issues. Staff have been educated on Reporting any abuse allegations, in particular to verbal, sexual and physical abuse, injury of unknown origin, staff to resident abuse that will affect all residents. They have been educated on reporting all allegations to the abuse coordinator and/or the co-coordinator. These reports are to be done immediately by the person who witnesses abuse. This was completed by 2-10- by Administrator, DON, Nurse consultant, CEO, COO. 3. All nursing department employees will be in serviced on reporting abuse and neglect with special attention to sexual abuse and neglect. All nursing department employees will be in serviced on resident rights. Licensed Nursing staff will be in serviced on reporting incidents, unusual occurrences and assessment post incident to all involved family members and physicians, and interventions post incidents by 2-10-22 through computer-based training beginning 2-6-2022. Staff not completing will be followed up daily, till completed by the HR Coordinator. The HR Coordinator will notify the Administrator daily of the staff that have not completed the in service. Nursing department employees will not be allowed to return to work after 2-14-22 if these trainings have not been completed. The facility Abuse Neglect Policy was in serviced with the Administrator with an emphasis when and what to report, by the COO as to notifications, investigations, and reporting, this was completed on 2-6-2022. Staff were educated in particular to verbal, sexual, physical abuse, injury of unknown origin. That all allegations will be reported to the abuse coordinator by the person who witnessed the abuse. The abuse coordinator will report all allegations to the appropriate state agencies and authorities. No changes were made to the current Abuse Neglect Policy. 4. Administrator or designee will monitor all incident reports to ensure proper interventions and investigations are in place during review of incident reports Monday through Friday during the daily stand-up meetings beginning 2-7-2022 and this will be an ongoing process. Administrator and director of nursing will look for situations that have the potential to have been abuse through the review of incidents and further the investigation. They will report all allegations of abuse to the appropriate state agencies and authorities. This would include physician and family notifications, update of resident care plan interventions. The QAPI team will establish a subcommittee to meet weekly x4 weeks then review with the QAPI team to re-evaluate. The QAPI subcommittee meeting is on 02/10/2022. The subcommittee will include a corporate member, the Administrator, a Nurse Administrator and one other member of team. Negative findings will be reported to the QAPI committee monthly, the next meeting will be on 02/16/2022. Process will continue until no negative findings are identified and facility has shown compliance. The QAPI meeting minutes will be sent to the facility's corporate nurse to review monthly to see if the facility needs further systemic changes or training. Onsite Verification: The IJ was removed on 02/13/2022 at 10:25 AM after the survey team performed onsite verification that the Removal Plans had been implemented. A review of in-service logs revealed 51 staff out of a total of 54 had signed they received the training related to abuse and neglect and reporting requirements. The Administrator was also in-serviced on 02/06/2022 on the abuse protocol. A review of a QAPI (quality assurance performance improvement) subcommittee meeting on 02/10/2022 revealed that abuse and neglect reporting requirements was being followed in QAPI and would continue to be going forward. Further review of QAPI minutes for a meeting on 02/12/2022 revealed abuse and neglect reporting requirements was reviewed again. Interview with fifteen staff members (two LVNs, two RNs, two housekeeping staff, four CNA's, one NA, two dietary staff, one medication aide and the Administrator) revealed all staff had received in-service training on abuse and neglect. Texas Administrative Code (TAC) S554.602(a)(1)(B), Tag 1304. The requirement is not met as evidenced by: For evidence of violation refer to CMS Form 2567 dated 02/13/2022, F609.

Based on interviews, record reviews, and facility policy review, it was determined that the facility failed to ensure cognitively impaired residents were free from physical, verbal, and sexual abuse for 3 (Resident #31, Resident #25, and Resident #12) of 3 residents reviewed for abuse. Specifically, the facility failed to address Resident #31 and Resident #25's behaviors and prevent both residents from physically and sexually abusing residents on the secured unit. The facility also failed to prevent staff from holding down Resident #12 when administering medications. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 (Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of K. The IJ began on 04/21/2020 when Resident #31 walked up to another resident that morning and kissed that resident on the mouth and nothing was put in place by the facility to protect that resident or other potential victims. The Administrator and DON were notified of the IJ on 02/05/2022 at 9:30 AM and provided the IJ Template at 9:54 AM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 02/09/2022 at 11:23 AM. The IJ was removed on 02/13/2022 at 10:25 AM after the survey team performed onsite verification that the Removal Plans had been implemented. Noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that was not immediate jeopardy for F600. Findings included: Review of the facility policy titled, Abuse and Neglect, revised 08/28/2017, revealed, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart .Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or other volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals .C. Prevention. The facility will provide the residents, families, and staff an environment free from abuse and neglect .4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse. 1. A review of the face sheet revealed the facility admitted Resident #31 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the discharge Minimum Data Set (MDS), dated [DATE], indicated that Resident #31 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated severe cognitive impairment. Resident #31 required supervision with set-up assistance with bed mobility, dressing, and toileting. Resident #31 required limited assistance of one person with eating. A review of the care plan, initiated on 08/01/2021, revealed the resident had the potential to exhibit behaviors such as physical aggression, hollering and cussing, and grabbing staff and other residents. Further review revealed Resident #31 had been exposing themself to female residents, and staff were to re-direct the resident as needed for behaviors. A review of nursing progress notes between July 2021 and January 2021 revealed the following: - On 07/14/2021 at 6:05 PM: Resident #31 walked up to another resident and kissed the resident on the mouth that morning. The other resident did not resist. The residents were separated at the time. Resident #31 had been very moody during the shift and was quick to curse at staff when the resident asked for something and did not get the response the resident wanted. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 07/27/2021 at 3:21 PM: Resident #31 had been placing resident's hands high up on a female resident's thigh and kissing other residents. Staff informed the residents that those behaviors weren't allowed but the residents continued and had to be physically separated. The residents were remined to keep their hands to themselves, but they resumed their activity after a few minutes. The staff re-enforced the rules. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 07/30/2021 at 2:27 PM: Resident #31 was observed kissing one of the female residents on the lips and both residents were separated and reminded that this type of activity was not allowed. The residents voiced understanding but then Resident #31 tried to lead a female resident to the resident's room. Staff informed the residents that was not allowed. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 08/07/2021 at 8:53 PM: Resident #31 was observed trying to hold hands and kiss female resident on the lips and the residents were redirected. Resident stated, Well it wasn't a kiss really and walked off. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 08/27/2021 at 2:54 PM: Resident #31 was observed putting their hand on a female resident's breast and the resident was told that type of behavior was not allowed. The resident got up and went to the resident's room. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 08/30/2021 at 3:02 AM: Resident #31 noted to have sexual behaviors this shift that required redirection. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 09/01/2021 at 2:55 PM: Resident #31 recently had an increase in sexual advances to the female residents and exposing themselves. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 10/09/2021 at 5:44 PM: Resident #31 had the hand of one of the female residents up in the resident's private area. The residents were redirected. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 10/13/2021 at 2:56 PM: Resident #31 was caught fondling the breast of one of the female residents. The resident was redirected. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 10/25/2021 at 1:02 PM: Resident #31 was observed kissing on female residents, touching female residents' breasts, and encouraging them to touch the resident's private area. The resident was redirected. The note indicated a fax was sent to the physician. - On 12/05/2021 at 10:44 AM: Resident #31 continued to encourage female residents to touch the resident's private area and kiss them on the lips. The resident was redirected. Further review revealed the family and DON were notified but there was no documentation that the physician was notified. - On 12/05/2021 at 11:55 PM: Resident #31 was observed grabbing a female resident's right arm in an aggressive manner and told the female resident to shut up which scared the female resident. The staff explained that behavior was no appropriate. The resident was later observed kissing another female resident. The staff explained to the resident that it was inappropriate and educated the resident on the rules of keeping resident hands to themselves. The resident indicated they understood. Further review revealed the family and physician were notified. - On 01/01/2022 at 4:04 PM: Resident #31 gave a female resident a hug and tried to kiss the female resident and put the female resident's hand on the resident's private parts. Staff reminded the resident that type of activity was not allowed. The note indicated the resident had been exhibiting verbal aggression towards staff. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 01/02/2022 at 11:55 AM: Resident #31 was making sexual advances to a female resident again and continued to display verbal aggression when redirected. Further review revealed a fax was sent to the physician, but there was no documentation the family was notified. A review of physician orders, dated 10/27/2021, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated to monitor for decreased incidents in behaviors. A review of physician orders, dated 12/07/2021, revealed a new order for [MEDICATION(S)] 25 mg at bedtime for hypersexuality incidents. This order was started following a re-admission to the facility. A review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with Nursing Assistant (NA) B on 02/03/2022 at 2:35 PM revealed that when staff observed residents exhibiting aggressive or inappropriate sexual behavior they were only supposed to attempt to separate the residents and had not been trained or instructed to do anything else. NA B stated she had participated in training for abuse and neglect a few times and that concerns should be reported to the administrator immediately. An interview on 02/03/2022 at 3:09 PM with Registered Nurse (RN) B revealed if residents on the dementia unit showed verbally or sexually inappropriate behaviors towards other residents, then the staff would tell that resident that behavior was not allowed. RN B stated if the resident became more aggressive, staff would report that to the DON or send a message to the physician. RN B stated staff would try to talk to the resident about the behavior and explain to them that it was not acceptable and try to redirect them or separate them. RN B stated staff would contact the responsible party of the resident with the behaviors, but they did not contact the family of the other resident. RN B stated staff should contact both families, but she never thought about that before now. RN B stated staff completed training related to abuse and neglect annually. An interview on 02/03/2022 at 6:10 PM with Licensed Vocational Nurse (LVN) B revealed the types of abuse were physical, emotional, and psychological. LVN B was asked if certain sexual behaviors would be considered abuse and stated in residents with cognitive deficits such as dementia, inappropriate sexual behaviors could be expected and would not always be considered sexual abuse. LVN B stated sexual behaviors towards other residents could be accepted because those behaviors were a part of a dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN B stated the behaviors would be discouraged but residents such as Resident #31 were not cognitively intact and could not retain the redirection. LVN B stated Resident #31's behaviors were not considered sexual abuse because they were cognitively impaired and that was expected as part of their diagnoses. LVN B stated Resident #31 frequently displayed sexual behaviors towards other residents that consisted of inappropriate touching, exposing themself, kissing other residents, and placing female resident's hands on Resident #31's genitals, and was on several medications to decrease the behaviors. LVN B stated the only nonpharmacological interventions attempted for Resident #31 was constant redirection, which had not been an effective intervention. LVN B stated if the sexual behaviors displayed by Resident #31 were viewed from the victim's perspective it would be considered sexual abuse. LVN B stated the victims should have been assessed for injuries and notifications made to the state agency, family, DON, and physician after every inappropriate sexual behavior and an investigation completed. LVN B confirmed no action was taken other than redirection. An interview with NA C on 02/04/2022 at 9:15 AM revealed Resident #31 used a lot of profanity, but she had never observed the resident bothering the female residents. NA C was aware that Resident #31 had sexually inappropriate behaviors. NA C stated she had never been trained or told how to respond to residents with those types of behaviors. NA C stated staff were doing training monthly for abuse and neglect and did computer-based training for dementia care but could not remember the last training that was completed. An interview with Certified Nursing Assistant (CNA) C on 02/04/2022 at 1:24 PM revealed that Resident #31 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA C stated Resident #31 yelled and used profanity at other residents and could be sexually inappropriate by asking female residents to touch residents' private areas. CNA C stated that staff would intervene and ask the resident to go to their room and move the other resident to a different area. CNA C stated she could not remember if she had been told to try to do anything else to address resident behaviors. CNA C stated that staff received training related to abuse and neglect quarterly and that all concerns should be reported to the administrator. An interview on 02/04/2022 at 1:46 PM with RN A revealed Resident #31 was verbally aggressive and cussed at staff a lot. RN A stated that she was aware that Resident #31 had sexually inappropriate behaviors towards other residents, but she had never witnessed them. An interview on 02/04/2022 at 6:30 PM with LVN H revealed Resident #31 had sexually inappropriate behaviors towards other residents but she was unaware of any recent incidents that had occurred. LVN H stated that Resident #31 was discharged back to the community to live with family for a short period, but the family readmitted the resident due to their aggressive and sexual behaviors towards family members. LVN H stated when residents exhibited those types of behaviors that staff just redirected them. An interview on 02/05/2022 at 9:01 AM with the Assistant Director of Nursing (ADON) revealed that Resident #31 had their medications changed and that had helped with the behaviors. She had not heard of that many incidents occurring recently. The ADON stated that when there were behaviors, staff would separate the residents and then try to redirect the other resident by offering food or something else they liked. The ADON stated that all families and the physician should be notified but she was not aware that the victim residents' families were not being notified when incidents occurred. The ADON stated she could not remember why she did not notify the physician, family, or the Administrator after the incident she documented that occurred in August 2021 with Resident #31 and a female resident. The ADON stated she did not remember who the other resident was. The ADON stated any incidents that were suspected abuse should be reported to the DON and administrator. An interview on 02/06/2022 at 1:10 PM with the Administrator revealed he had not reported or investigated any of the incidents and that he was not aware of any of them. The Administrator stated he felt it was a breakdown of communication with staff and felt that staff were not reporting things to him that should be reported and investigated. The Administrator stated staff completed computer-based trainings on abuse and neglect reporting but did not state how often this was done. The Administrator stated he completed impromptu quizzes of staff in the hallways on the abuse protocol. The Administrator stated he agreed all of the incidents documented in progress notes for Resident #31 should have been reported and investigated. A telephone interview on 02/09/2022 at 5:37 PM with the Director of Nursing (DON) revealed that if there was a resident-to-resident incident it should only be reported if there was an injury. The DON stated that after an incident, nurses would assess a resident for any injury, but the DON was unable to state how staff would assess a resident for emotional or psychological harm. The DON stated if there was a sexual incident between residents that it would only be abuse if the act was carried out and that it was not abuse if it was just attempted. The DON stated that just a simple kiss between residents was not abusive. The DON also stated that an investigation would determine if an incident needed to be reported and felt that two hours was sufficient time to determine if an incident was abuse and needed to be reported. 2. A review of the face sheet revealed the facility admitted Resident #25 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the discharge Minimum Data Set (MDS), dated [DATE], indicated that Resident #25 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated severe cognitive impairment. Resident #25 required extensive assistance of two staff with bed mobility, dressing, and toileting. Resident #25 required limited assistance of one person with eating. A review of the care plan, initiated on 08/01/2021, revealed the resident had the potential to exhibit behaviors such a physical aggression, Further review revealed Resident #25 had sexually inappropriate behaviors. Staff were to explain to the resident acceptable sexual expressions, listen and talk to resident, and see if the resident would explain why they did the behavior. A review of nursing progress notes between July 2021 and January 2021 revealed the following: - On 07/02/2021 at 2:20 PM: Staff heard a loud thud and overheard the CNA tell Resident #25 not to hit another resident like that. The CNA reported that the resident hit another resident in the chest. When the resident was asked about the incident, the resident made a threat towards staff. The residents were separated. Staff assessed the resident who was hit but no bruise was visible on the resident's chest. Staff were unable to redirect the resident. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 07/02/2021 at 2:54 PM: Staff observed Resident #25 in his wheelchair in the hallway with their penis pulled out. Staff explained to the resident that was inappropriate behavior. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 07/08/2021 at 11:21 PM: Overhead Resident #25 tell their roommate that the resident would beat them up. Staff redirected the resident successfully and the resident apologized to the roommate. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 08/03/2021 at 7:45 AM: Resident #25 was observed with the resident's hand on a female resident's leg and with the resident's privates out in other hand. The resident was redirected multiple times. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 09/21/2021 at 2:52 PM: Staff overheard Resident #25 tell one of the female residents that the resident was going to get it out and work on it. Staff redirected the resident to the resident's room. The note did not indicate the physician or family was notified and there was no additional follow-up. - On 01/20/2022 at 6:53 AM: Staff observed Resident #25 hollering at residents and then staff observed fluid all over Resident #25 and saw another resident holding an empty cup in their hand as they walked towards their room. Further review revealed the family was notified but there was no documentation that the physician was notified. A review of physician orders, dated 08/03/2021, revealed and order for [MEDICATION(S)] 25 mg (milligrams) at bedtime for hypersexuality incidents. An interview with Nursing Assistant (NA) B on 02/03/2022 at 2:35 PM revealed that when staff observed residents exhibiting aggressive or inappropriate sexual behavior they were only supposed to attempt to separate the residents and had not been trained or instructed to do anything else. NA B stated she had participated in training for abuse and neglect a few times and that concerns should be reported to the administrator immediately. An interview on 02/03/2022 at 3:09 PM with Registered Nurse (RN) B revealed if residents on the dementia unit showed verbally or sexually inappropriate behaviors towards other residents, then the staff would tell that resident that behavior was not allowed. RN B stated if the resident became more aggressive, staff would report that to the DON or send a message to the physician. RN B stated staff would try to talk to the resident about the behavior and explain to them that it was not acceptable and try to redirect them or separate them. RN B stated staff would contact the responsible party of the resident with the behaviors, but they did not contact the family of the other resident. RN B stated staff should contact both families, but she never thought about that before now. RN B stated staff completed training related to abuse and neglect annually. An interview on 02/03/2022 at 6:10 PM with Licensed Vocational Nurse (LVN) B revealed the types of abuse were physical, emotional, and psychological. LVN B was asked if certain sexual behaviors would be considered abuse and stated in residents with cognitive deficits such as dementia, inappropriate sexual behaviors could be expected and would not always be considered sexual abuse. LVN B stated sexual behaviors towards other residents could be accepted because those behaviors were a part of a dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN B stated the behaviors would be discouraged but residents such as Resident #25 were not cognitively intact and could not retain the redirection. LVN B stated Resident #25 had occasionally displayed sexual behaviors towards other residents, which consisted of exposing themself to other residents, and the only interventions taken were redirection. LVN B stated Resident #25's behaviors were not considered sexual abuse because they were cognitively impaired and that was expected as part of their diagnoses. An interview with Certified Nursing Assistant (CNA) C on 02/04/2022 at 1:24 PM revealed that Resident #25 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 02/05/2022 at 9:01 AM with the Assistant Director of Nursing (ADON) revealed that when there were behaviors, staff would separate the residents and then try to redirect the other resident by offering food or something else they liked. The ADON stated that all families and the physician should be notified but she was not aware that the victim residents' families were not being notified when incidents occurred. The ADON stated any incidents that were suspected abuse should be reported to the DON and administrator. An interview on 02/06/2022 at 1:10 PM with the Administrator revealed he had not reported or investigated any of the incidents and that he was not aware of any of them. The Administrator stated he felt it was a breakdown of communication with staff and felt that staff were not reporting things to him that should be reported and investigated. The Administrator stated staff completed computer-based trainings on abuse and neglect reporting but did not state how often this was done. The Administrator stated he completed impromptu quizzes of staff in the hallways on the abuse protocol. The Administrator stated he agreed all of the incidents documented in progress notes for Resident #25 should have been reported and investigated. A telephone interview on 02/09/2022 at 5:37 PM with the Director of Nursing (DON) revealed that if there was a resident-to-resident incident it should only be reported if there was an injury. The DON stated that after an incident, nurses would assess a resident for any injury, but the DON was unable to state how staff would assess a resident for emotional or psychological harm. The DON stated if there was a sexual incident between residents that it would only be abuse if the act was carried out and that it was not abuse if it was just attempted. The DON stated that just a simple kiss between residents was not abusive. The DON also stated that an investigation would determine if an incident needed to be reported and felt that two hours was sufficient time to determine if an incident was abuse and needed to be reported. 3. A review of the facility face sheet revealed Resident #12 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Medicare 5-day PPS (Projected Payment System) Minimum Data Set (MDS) assessment, dated 01/28/2022, indicated the resident had severe cognitive impairment with no behaviors. Further review of the MDS indicated the resident required supervision to limited assistance of one person for their activities of daily living (ADLs). The resident received antipsychotic and antidepressant medication seven out of seven days during the assessment period. A review of the care plan dated 11/04/2021 indicated Resident #12 required [CONDITION(S)] medications, [MEDICATION(S)] (an antipsychotic) and [MEDICATION(S)] (medication used to treat [CONDITION(S)] disorders), for behavior management with a goal to be free of drug related complications. Interventions included: -Administer medications as ordered. Monitor/document for side effects and effectiveness. -Consult with pharmacy and physician to consider dosage reduction when clinically appropriate. -Discuss with the physician and family the ongoing need for use of medication. -Monitor/record occurrence for target behaviors symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. -Monitor/record/report to the physician as needed (PRN) side effects and adverse reactions of psychoactive medications. -Obtain and monitor labs as ordered and report to the physician. A review of progress notes dated 11/03/2021 at 5:50 AM written by Licensed Vocational Nurse (LVN) E indicated the nurse and the Certified Nurse Aide (CNA) held the resident down to give an IM injection of [MEDICATION(S)] after it was received from the pharmacy, due to resident becoming combative. During an interview with LVN E on 02/10/2022 at 3:47 PM, she stated she was an agency nurse that had been coming to the facility for a couple of months. LVN E stated the Certified Nurse Aide (CNA) H working with her the night she administered [MEDICATION(S)] to Resident #12 told her the resident was being aggressive and started hitting him. LVN E stated the CNA's mother was working as the nurse on the other side of the building (LVN C) and she came over and gave the shot of [MEDICATION(S)] while CNA H held the resident's legs, and she held the resident's upper body. LVN E reported the resident had been agitated earlier in the shift and she had called the physician and he ordered [MEDICATION(S)] injectable, but it was not in the e-kit and the pharmacy had not delivered it until later. LVN E stated LVN C had been able to get Resident #12 to take [MEDICATION(S)] earlier in the shift which seemed to help a little but then the CNA H reported the resident was being combative and went and got his mom, LVN C. Several attempts to contact CNA H were made during the survey with no return call received before exit. During an interview with LVN C on 02/10/2022 at 4:35 PM, she stated Resident #12 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN C stated CNA H did assist with holding the resident so the shot could be given because the resident was being combative. A review of a progress notes on 11/12/2021 at 4:27 PM written by LVN F indicated Resident #12 refused to take [MEDICATION(S)] and stated I'm not taking any more meds. I'd rather be dead than take any more meds. The note indicated a [MEDICATION(S)] injection was given and was documented as being ineffective at 5:00 PM. During an interview with LVN F on 02/10/2022 at 4:51 PM, she stated the resident was becoming increasingly agitated throughout the day on 11/12/2021 and the Director of Nursing (DON) told her to give the resident a shot of [MEDICATION(S)]. LVN F stated the resident did have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she did not return to the facility after that day because she did not agree with the facility's policies and did not feel comfortable giving the injection but was doing what she was told by her supervisor. The DON was not available for further interview after 02/09/2022. A review of progress notes on 11/25/21 written by Registered Nurse (RN) B indicated the resident refused their morning medications and became increasingly agitated after speaking with family members on the phone. A health status note on 11/25/2021 at 12:06 PM indicated the resident's scheduled medications were put in their lunch and they ate all their lunch. At 3:40 PM the resident started becoming upset, wanting to leave the facility, and was told if they did not settle down that they would be given a shot. At 4:29 PM, the Assistant Director of Nursing (ADON) was notified of the resident's behaviors and instructed the staff to administer a [MEDICATION(S)] injection. At 4:40 PM staff from the other wing to assist in administering the [MEDICATION(S)]. During an interview with RN B on 02/08/2022 at 12:35 PM, RN B stated they had to give [MEDICATION(S)] to Resident #12 a couple of times after the resident first admitted to the facility because the resident was demanding to call and threatening the family on the phone, beating on the door, knocking over everything on the over bed table, threw a table, and wanting to call the police. RN B stated she got another staff member to hold the resident, a strong CNA, because she would not be able to do it on her own. RN B stated she could not recall what CNA assisted her. During a previous interview on 02/07/2022 at 2:15 PM, RN B stated they had [MEDICATION(S)] on the medication cart for both Resident #11 and Resident #12 but neither one currently had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 02/12/2022 at 10:07 AM, the ADON stated that since the current survey, she felt differently about PRN [CONDITION(S)] medication use and felt more education was needed. The ADON stated that she felt that residents should be allowed as much time as necessary when refusing medication or exhibiting behaviors before the decision was made to administer a PRN [CONDITION(S)]. An interview on 02/12/2022 at 10:54 AM with the Administrator revealed he agreed that other alternative measures that were nonpharmacological should be explored prior to administering PRN [CONDITION(S)] medications. Removal Plan: 1. On 2-5-22, NP with psych services did a telehealth visit with Resident #31 and added a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A referral was made to two Psychiatric Hospitals and was denied by both hospitals. One for last behavior being greater than 30 days and the other hospital was not taking admissions due to not have beds for placement. Facility will continue nonpharmacological interventions such letting resident call his friend and family as requested, adding psych services for counseling, continued redirection of resident and reinforcement of inappositeness of actions, increased monitoring of resident's location, music and memory, aroma therapy, and activities su

Based on observations, interviews, record reviews, document review, and facility policy review, it was determined that the facility failed to identify causal factors related to falls, thoroughly investigate every fall incident, implement and evaluate interventions to prevent falls, provide appropriate and sufficient supervision for residents who were at risk for falls, and prevent residents with identified exit-seeking behaviors from eloping from the facility. This affected 5 (Resident #30, Resident #25, Resident #241, Resident #3, and Resident #11) of 7 residents reviewed for accident hazards. This deficient practice resulted in Resident #30 falling and suffering from a left femur fracture. Findings included: A review of the facility policy, titled, Preventive Strategies to Reduce Fall Risk, revised 05/20/2011, revealed, Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. A review of the facility policy titled, Secure Unit and Residents at Risk for Elopement, revised 02/01/2007, revealed, The Secured Care Unit may be used to keep residents who are a high risk for elopement safe from exiting the facility. The resident should have an Elopement Risk Assessment completed and a physician order completed. A review of the facility's policy titled, Fall Risk Assessment, dated 02/01/2007, indicated Preventing falls requires an interdisciplinary program that focuses on modifying the extrinsic factors, correcting intrinsic factors, and educating the resident and family. A fall Risk Assessment will be completed on admission, quarterly and as needed .Interventions will focus on manipulating the environment, educating the resident and family, implementing rehabilitation programs to improve functional abilities in ADLs, and careful monitoring of medication side effects .All falls will be investigated by the Charge Nurse. The nurse will complete an incident report and a subsequent investigation report and forward to the DON or designee by the end of the current shift. Falls resulting in sentinel event will be reported to the DON .The facility administration will review at least monthly Incident and Accident Reports regarding safety issues. And refer to QAPI Committee any potential trends and/or concerns. The QAPI Committee will use the report as a foundation for performance improvement opportunities. 1. A review of the face sheet revealed the facility admitted Resident #30 with diagnoses including Alzheimer's, major depressive disorder, unspecified abnormalities of gait and mobility, unspecified lack of coordination, repeated falls, and essential hypertension. A review of the quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #30 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated severe cognitive impairment. Resident #30 required supervision with set-up for bed mobility and eating, limited assistance of one staff with transfers, and extensive assistance of one staff with toileting. Further review indicated that Resident #30 only ambulated on or off the unit once or twice during the seven day look back period. The resident required supervision with locomotion on and off the unit. A review of the care plan, initiated on 11/13/2018, revealed the resident had the potential for falls. Further review revealed interventions included: anticipate and meet resident needs, be sure call light is within reach and encourage resident to use it for assistance, review information on past falls and attempt to determine cause of falls, follow facility fall protocol, remind resident to alert staff if the resident happens to fall in the room, ensure that the resident is wearing appropriate footwear when ambulating, encourage resident to notify staff if their feeling dizzy, encourage and educate resident often on asking for assistance when transferring, and educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Further review of the care plan revealed the last update was 10/24/2019. A review of the falls risk assessment, completed on 03/24/2021, revealed the resident scored a 20, which meant the resident was considered a high fall risk. A review of a fall incident report, dated 02/01/2021, revealed the resident was found sitting on the floor in the hallway by the resident's doorway. The resident stated they fell due to their shoes making them slip. The resident had a 1 cm (centimeter) x 10 cm bruise to the right forearm. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. A review of a fall incident report, dated 03/05/2021, revealed staff heard banging on a door and when staff went to check, they heard the resident saying, Help me. The resident was found on the bathroom floor lying on their back. The resident had a knot to the left hip and complained of severe pain. The physician was notified, and an order was received to send the resident to the emergency room (ER). A further review revealed the facility failed to conduct an investigation to identify causal factors related to the fall or identify and implement appropriate interventions. A review of a hospital emergency room department exam, dated 03/05/2021, revealed there appeared to be an old fracture of the right pelvis, a moderately displaced fracture through the left pubic symphysis (joint between left and right hip) that may be chronic, and subtle lucency in the right superior sacrum which may represent a nondisplaced fracture. The exam indicated an MRI (magnetic resonance imaging) should be considered for further evaluation. A review of a nursing progress note, dated 03/06/2021 at 4:22 PM, revealed the resident had transferred several times from the bed to the wheelchair with staff assistance, but still complained of pain that increased during transfers even after pain medication had been administered. The resident remained very guarded of the left leg due to pain and was not putting weight on the left leg when transferring. A review of a nursing progress note, dated 03/07/2021 at 5:48 PM, revealed the resident had been up in wheelchair two times but had increased pain to the left leg during transfers. Swelling to the left leg was noted and the resident indicated the pain medication helped, but the pain never completely went away. A review of a nursing progress note, dated 03/11/2021 at 9:24 PM, revealed, orders given to x-ray left femur. A review of an X-ray, dated 03/11/2021, revealed an acute fracture to the distal left femur (thigh bone just above the knee joint). A review of a fall incident report, dated 03/16/2021, revealed the resident was yelling, and staff went to the resident's room and saw the resident sitting on the floor. When staff entered the room, the resident was sitting on the floor beside the bed with blood in their hair. The resident stated they were trying to get something from the closet. The resident had a 6 cm x 1.1 cm cut to the head. The physician was notified, and an order was received to send the resident out to the ER. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. A review of a nursing progress note, dated 03/11/2021 at 11:08 PM, revealed the nurse from the ER called to let the staff know that the resident was returning to the facility, and the CT (computerized tomography) scan was clear. The nurse from the ER informed the staff that the resident had six to seven sutures to the wound. A review of a fall incident report, dated 03/29/2021, revealed the resident had an un-witnessed fall. Staff observed the resident lying on the floor in the hallway right outside the resident's room. The resident was lying on their back, with a wheelchair by the foot of the bed in the resident's room. No injuries were noted. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. A review of a fall incident report, dated 05/12/2021, revealed staff found the resident on the floor beside the bed. The resident stated they slid out of bed while attempting to transfer to the wheelchair. No injuries were noted. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. A review of a fall incident report, dated 07/04/2021, revealed staff witnessed another resident grab the handles of Resident #30's wheelchair, lifted it and dumped the resident on the floor. The resident landed on their left hip and left elbow and hit their head on the door that went to the courtyard. No injuries were noted. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. A review of a fall incident report, dated 09/02/2021, revealed staff heard a loud thud and observed the resident sitting on the floor. The resident stated they were trying to get up from the wheelchair and the wheelchair moved. No injuries were noted. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. A review of a fall incident report, dated 09/10/2021, revealed staff observed the resident walk behind their wheelchair and start to fall. The resident assisted themself down by grabbing onto the side rails on the wall. No injuries were noted. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. A review of a fall incident report, dated 09/17/2021, revealed the resident reported standing up out of the wheelchair and lost their balance. The resident was resistive when staff tried to assist. No injuries were noted. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. A review of a fall incident report, dated 10/10/2021, revealed the resident reported standing up out of bed and fell on their buttocks. No injuries were noted. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. A review of a fall incident report, dated 10/22/2021, revealed staff observed the resident down the hallway, sitting on the floor in front of their room. No injuries were noted. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. A review of a fall incident report, dated 11/24/2021, revealed staff heard a noise in the hallway and found the resident in front of their wheelchair, lying on their back. No injuries were noted. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. A review of a fall incident report, dated 12/18/2021, revealed staff heard a noise in the hallway and found the resident in front of their wheelchair, lying on their back in front of another resident's room. No injuries were noted. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. A review of a fall incident report, dated 01/24/2022, revealed the resident was at the nurses' station and reported that the resident fell and hit their head. A 3 cm x 5 cm nodule was observed to the left side of the back of the resident's head. No staff reported hearing any sounds prior. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. A review of a fall incident report, dated 01/29/2021, revealed staff found the resident on the floor in the hallway of the unit. Their wheelchair was in the unit by the exit door leading to the hallway. A small hematoma was noted to the back of the head. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. An interview with Nursing Assistant (NA) B on 02/03/2022 at 2:35 PM revealed that staff tried to keep residents towards the front of the locked unit so staff could monitor them to prevent falls. NA B stated staff tried to redirect Resident #30 and encourage them to use their wheelchair. NA B stated that she thought it was helpful to use redirection as an intervention with residents that had cognitive issues and were diagnosed with dementia. NA B stated she was not sure of what other interventions were in place for the resident. NA B also stated that she was not sure of what was on the resident's care plan since she did not have access to them. An interview on 02/03/2022 at 3:09 PM with Registered Nurse (RN) B revealed that when a resident had a fall, staff first assessed the resident and checked for any possible injuries, got vitals, and returned the resident to where they were prior to the fall if it was safe to do so. RN B stated if it was an unwitnessed fall or a suspected head injury, nursing staff would start neurological (neuro) checks and notify the responsible party, DON, and the physician. RN B stated that nurses completed the risk assessment, but RN B stated she did not know what the root cause analysis was or who was responsible for identifying interventions or updating the care plan. RN B stated she completed some of the fall incident reports for Resident #30 but only listed the description of the fall and did not identify root cause or interventions because that was not her responsibility, and she did not know whose responsibility it was. RN B stated she was not even sure who all had access to care plans or if CNA staff could access them. RN B stated that staff would check on Resident #30 more often, but she was not sure what other interventions were care planned for the resident. RN B stated that staff gave the resident a lot of reminders and staff felt like if the residents heard it over and over, they might retain it, but admitted that the resident would not retain information long term. An interview with Certified Nursing Assistant (CNA) C on 02/04/2022 at 1:24 PM revealed that staff tried to redirect Resident #30 to call staff for assistance before ambulating and transferring unassisted to try and prevent additional falls from occurring. CNA C stated she was not aware of other interventions in place for fall prevention, and she had never been a part of a process to identify appropriate interventions for residents that were fall risks. CNA C stated that only nurses had access to the care plans and could see what interventions were listed. An interview on 02/04/2022 at 1:46 PM with RN A revealed that after a fall, staff assessed the resident for any injuries, provided aide if needed and notified the physician, got vitals, and started neuro checks if there was a head injury or if it was an unwitnessed fall. RN A stated that the DON and the IDT (interdisciplinary) team identified root cause and interventions, but she was not sure who was responsible for updating the care plan. RN A stated that staff tried to remind Resident #30 to stay in their wheelchair and ask staff to help assist with transfers. RN A stated the facility did not use restraints, so there were not a lot of other options. RN A admitted that reminding residents who have cognitive deficits was not effective or appropriate. An interview with NA C on 02/04/2022 at 9:15 AM revealed she was not sure what a care plan was because she had never seen one. NA C stated that staff reminded residents on the dementia unit who were a fall risk to ask and wait for assistance before attempting to transfer or get up unassisted. NA C also stated that due to the residents' cognitive deficits, they were not able to remember what staff reminded or told them to do, and it was not an effective fall prevention. NA C stated she was not sure why NA or CNA staff could not access the care plans and stated, That's a good question, when asked. An interview on 02/04/2022 at 6:30 PM with LVN H revealed that after a resident fell , staff assessed the resident head-to-toe and got their vitals. LVN H stated nursing staff were responsible for completing the risk management assessment and notifying the physician, DON, and family and starting neuro checks if the resident hit their head or if the fall was unwitnessed. LVN H stated she thought the ADON and/or the DON identified root cause and updated the care plan with new interventions. LVN H stated that CNA staff could not access the care plans, and she was not sure why, but agreed it would be beneficial since CNA staff provided the most direct care to residents. An interview on 02/05/2022 at 9:01 AM with the ADON revealed that after a fall occurred, CNA staff notified the nurse, and the nurse was responsible for assessing the resident head-to-toe to rule out injury and get vitals. The ADON stated if the resident hit their head or if the fall was unwitnessed, the nurse would start neuro checks. The ADON stated the nurse would also notify the physician, DON, and family and get an order if the resident needed to be sent out to the emergency room (ER) or order X-rays if a fracture was suspected. The ADON stated she was not sure who identified root cause and long-term interventions and knew the DON had their own process, but she was not sure what that process consisted of. The ADON stated she thought the MDS coordinator updated the care plan, but she was not exactly sure who was responsible for updating the care plans. An interview on 02/08/2022 at 1:59 PM with NA D revealed she did not know if Resident #30 was a fall risk. NA D stated she did not know what fall interventions were in place for the resident. NA D stated she did not know what a care plan was, and she had never seen one and she had never been shown where or how to access one. An interview on 02/09/2022 at 5:37 PM with the Director of Nursing (DON) revealed that when a fall occurred, CNA staff should notify the nurse and the nurse would complete all the notifications to the physician and family and complete all the assessments. The DON stated identifying the root cause of falls was a group effort and was discussed after reviewing the incident reports during the morning meeting. However, the DON stated this process with the findings was not documented anywhere. The DON stated she reviewed care plans, but the MDS coordinator was responsible for updating the care plan. The DON stated that she did feel it was an appropriate fall intervention to educate and remind residents that have cognitive deficits and that staff reminded them every day. During an interview on 02/11/2022 at 1:00 PM, the Medical Director (MD) stated fall prevention was the number one thing to be discussed for all residents during the MD's monthly visits to the facility. The MD stated interventions to prevent falls changed as resident conditions changed. The MD stated the facility reported falls to the MD via fax and was aware of all falls and did not see a problem with the process in place. An interview on 02/12/2022 at 9:50 AM with MDS Coordinator revealed it was the MDS coordinator's role to initiate and evaluate care plans and update them as needed. The MDS Coordinator stated she was new to that role and would not start training until 02/14/2022. The MDS Coordinator stated that she thought all staff that provided care to residents should have access to them. The MDS Coordinator stated that after a fall occurred, care plans should be evaluated for appropriate interventions and current interventions and new ones should be explored. The MDS Coordinator agreed that residents with cognitive deficits would not benefit from reminding or education since they would not retain the information and it would not assist with prevention. An interview on 02/12/2022 at 10:54 AM with the Administrator revealed he expected that care plans should be updated after a change in condition such as falls or elopements, and that they should be reviewed to ensure current interventions were appropriate and updated if new ones were identified. The Administrator also stated staff should be identifying root cause of falls and behaviors to better understand how to ensure safety and provide the overall best care. 2. A review of the face sheet revealed the facility admitted Resident #25 with diagnoses including major depressive disorder, dementia, Alzheimer's, and essential hypertension. A review of the discharge Minimum Data Set (MDS), dated [DATE], indicated Resident #25 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated severe cognitive impairment. Resident #25 required extensive assistance of two staff with bed mobility, transfer, dressing, and toileting. Resident #25 required limited assistance of one person with eating. Further review revealed Resident #25 did ambulate at all on or off the unit during the seven day look back period. A review of the care plan, initiated on 12/30/2021, revealed the resident was at moderate risk for falls. Further review revealed interventions included to anticipate and meet resident needs, be sure call light was within reach and encourage resident to use it for assistance, educate resident/family/caregivers about safety reminders and what to do when a fall occurs, and follow facility fall protocol. The resident did not have a care plan for falls prior to 12/30/2021. A review of a falls risk assessment, completed on 07/16/2021, revealed the resident scored a 16, which meant the resident was considered a high fall risk. A review of a fall incident report, dated 08/28/2021, revealed the resident was found sitting on the floor in their room with their back up against the bed with an abrasion to the left upper back, shoulder, and left and right knee. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. A review of a fall incident report, dated 09/21/2021, revealed the resident was found sitting near their bed, their brief was removed, and feces was on the floor. There was blood on the right side of the resident who was facing the wall. The resident had large bruising to the right elbow and a skin tear. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. A review of a fall incident report, dated 11/05/2021, revealed the resident was found lying on the floor mat next to the bed. No injuries were noted. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. A review of a fall incident report, dated 12/07/2021, revealed the resident was observed sitting in a wheelchair by the double doors on the dementia unit. Staff heard a noise and observed the resident on the floor with a right elbow skin tear. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. A review of a fall incident report, dated 12/10/2021, revealed the resident was observed on their knees on the floor in their room, up against the bed. No injuries were noted. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. A review of a fall incident report, dated 12/27/2021, revealed the resident was at the nurses' station for better observation. Staff heard a loud noise and observed the resident sitting on the floor with their back to the resident's door. No injuries were noted. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. A review of a fall incident report, dated 12/28/2021, revealed the resident was at the nurses' station for closer observation, sitting in a wheelchair, and then the resident suddenly fell out of the wheelchair and landed on their left side on the floor. A skin tear to the left elbow and a bruise and abrasion to the left temple were noted. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. A review of a fall incident report, dated 01/17/2022, revealed the resident was observed on the floor mat beside the bed, in an upright position. No injuries were noted. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. A review of a fall incident report, dated 01/23/2022, revealed staff heard a loud noise, and the resident was observed on the floor in their room, with their head slightly under the bed. The resident had a 4 cm (centimeter) x 4 cm hematoma to the front left side of the forehead. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. A review of a fall incident report, dated 01/26/2022, revealed the resident was found on the floor with the wheelchair in their hands when staff came down hallway. The resident had a 0.2 cm x 0.2 cm and 1 cm x 1 cm scratch to the top of the head. The facility failed to conduct an investigation into the causal factors related to the fall and identify and implement appropriate interventions. An interview with Nursing Assistant (NA) B on 02/03/2022 at 2:35 PM revealed that staff tried to keep residents towards the front of the locked unit so staff could monitor them to prevent falls. NA B stated staff tried to redirect Resident #25 and encourage them to use their wheelchair. NA B stated that she thought it was helpful to use redirection as an intervention with residents that had cognitive issues and were diagnosed with dementia. NA B stated she was not sure of what other interventions were in place for the resident. NA B also stated that she was not sure of what was on the resident's care plan, since she did not have access to them. An interview on 02/03/2022 at 3:09 PM with Registered Nurse (RN) B revealed that when a resident had a fall, staff first assessed the resident and checked for any possible injuries, got vitals, and returned the resident to where they were prior to the fall if it was safe to do so. RN B stated if it was an unwitnessed fall or a suspected head injury, nursing staff would start neurological (neuro) checks and notify the responsible party, DON, and the physician. RN B stated that nurses completed the risk assessment, but RN B stated she did not know what the root cause analysis was or who was responsible for identifying interventions or updating the care plan. RN B stated she completed some of the fall incident reports for Resident #25 but only listed the description of the fall and did not identify root cause or interventions because that was not her responsibility, and she did not know whose responsibility it was. RN B stated she was not even sure who all had access to care plans or if CNA staff could access them. RN B stated that Resident #25 had a fall mat beside their bed, and staff would try to get Resident #25 up before the resident tried to get up unassisted. RN B stated that staff gave the resident a lot of reminders and staff felt like if the residents heard it over and over, they might retain it, but admitted that the resident would not retain information long term. An interview with Certified Nursing Assistant (CNA) C on 02/04/2022 at 1:24 PM revealed that staff tried to redirect Resident #25 to call staff for assistance before ambulating and transferring unassisted to try and prevent additional falls from occurring. CNA C stated she was not aware of other interventions in place for fall prevention, and she had never been a part of a process to identify appropriate interventions for residents that were fall risks. CNA C stated that only nurses had access to the care plans and could see what interventions were listed. An interview on 02/04/2022 at 1:46 PM with RN A revealed that after a fall staff assessed the resident for any injuries, provided aide if needed and notified the physician, got vitals, and started neuro checks if there was a head injury or if it was an unwitnessed fall. RN A stated that the DON and the IDT (interdisciplinary) team identified root cause and interventions, but she was not sure who was responsible for updating the care plan. RN A stated that Resident #25 had a fall mat and staff tried to remind them to ask for staff assistance. RN A stated the facility did not use restraints, so there were not a lot of other options. RN A admitted that reminding residents who have cognitive deficits was not effective or appropriate. An interview with NA C on 02/04/2022 at 9:15 AM revealed she was not sure what a care plan was because she had never seen one. NA C stated that staff reminded residents on the dementia unit who were a fall risk to ask and wait for assistance before attempting to transfer or get up unassisted. NA C also stated that due to the residents' cognitive deficits, they were not able to remember what staff reminded or told them to do, and it was not an effective fall prevention. NA C stated she was not sure why NA or CNA staff could not access the care plans and stated, That's a good question, when asked. An interview on 02/04/2022 at 6:30 PM with LVN H revealed that after a resident fell , staff assessed the resident head-to-toe and got their vitals. LVN H stated nursing staff were responsible for completing the risk management assessment and notifying the physician, DON, and family and starting neuro checks if the resident hit their head or if the fall was unwitnessed. LVN H stated she thought the ADON and/or the DON identified root cause and updated the care plan with new interventions. LVN H stated that CNA staff could not access the care plans, and she was not sure why, but agreed it would be beneficial since CNA staff provided the most direct care to residents. An interview on 02/05/2022 at 9:01 AM with the ADON revealed that after a fall occurred, CNA staff notified the nurse, and the nurse was responsible for assessing the resident head-to-toe to rule out injury and get vitals. The ADON stated if the resident hit their head or if the fall was unwitnessed, the nurse would start neuro checks. The ADON stated the nurse would also notify the physician, DON, and family and get an order if the resident needed to be sent out to the emergency room (ER) or order X-rays if a fracture was suspected. The ADON stated she was not sure who identified root cause and long-term interventions and knew the DON had their own process, but she was not sure what that process consisted of. The ADON stated she thought the MDS coordinator updated the care plan, but she was not exactly sure who was responsible for updating the care plans. An interview on 02/08/2022 at 1:59 PM with NA D revealed that Resident #25 had a fall mat. NA D stated she did not know what fall interventions were in place for the resident. NA D stated she did not know what a care plan was, and she had never seen one and she had never been shown where or how to access one. An interview on 02/09/2022 at 5:37 PM with the Director of Nursing (DON) revealed that when a fall occurred, CNA staff should notify the nurse and the nurse would complete all the notifications to the physician and family and complete all the assessments. The DON stated identifying the root cause of falls was a group effort and was discussed after reviewing the incident reports during the morning meeting. However, the DON stated this process with the findings was not documented anywhere. The DON stated she reviewed care plans, but the MDS coordinator was responsible for updating the car[TRUNCATED]

Based on observations, interviews, record reviews, document review, and facility policy review, it was determined that the facility failed develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 5 of 5 (Resident #30, #25, #11, #3 and #28) reviewed for care plans. The facility failed to update care plans after falls and elopements with appropriate interventions to ensure the safety of Resident #30, Resident #25, Resident #11, Resident #3, and Resident #28. The facility also failed to update care plans for Resident #19 related to bathing refusals. This affected 6 (Resident #30, Resident #25, Resident #11, Resident #3, Resident #28, and Resident #19) of 16 residents reviewed for care planning. This deficient practice resulted in Resident #30 falling and suffering from a left femur fracture. Findings included: A review of the facility's policy titled, Care Plans, dated 02/13/2017, indicated, The comprehensive care plan will be reviewed regularly, as per guideline, and/or with significant change and revised by a team of qualified persons after each assessment .The care plan will be maintained on the resident's clinical record and will be made available to all direct care staff. 1. A review of the face sheet revealed the facility admitted Resident #30 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #30 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated severe cognitive impairment. Resident #30 required supervision with set-up for bed mobility and eating, limited assistance of one staff with transfers, and extensive assistance of one staff with toileting. A review of the care plan, initiated on 11/13/2018, revealed the resident had the potential for falls. Further review revealed interventions included: anticipate and meet resident needs, be sure call light is within reach and encourage resident to use it for assistance, review information on past falls and attempt to determine cause of falls, follow facility fall protocol, remind resident to alert staff if the resident happens to fall in the room, ensure that the resident is wearing appropriate footwear when ambulating, encourage resident to notify staff if their feeling dizzy, encourage and educate resident often on asking for assistance when transferring, and educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Further review of the care plan revealed the last update was 10/24/2019. A review of the falls risk assessment, completed on 03/24/2021, revealed the resident scored a 20, which meant the resident was considered a high fall risk. A review of a fall incident report, dated 02/01/2021, revealed the resident was found sitting on the floor in the hallway by the resident's doorway. The resident stated they fell due to their shoes making them slip. The resident had a 1 cm (centimeter) x 10 cm bruise to the right forearm. A further review revealed no causal factors related to the fall or appropriate interventions were identified. The care plan was not updated following this fall. A review of a fall incident report, dated 03/05/2021, revealed staff heard banging on a door and when staff went to check, they heard the resident saying, Help me. The resident was found on the bathroom floor lying on their back. The resident had a knot to the left hip and complained of severe pain. The physician was notified and an order was received to send the resident to the emergency room (ER). A further review revealed no causal factors related to the fall or appropriate interventions were identified. A review of a hospital emergency room department exam, dated 03/05/2021, revealed there appeared to be an old fracture of the right pelvis, a moderately displaced fracture through the left pubic symphysis (joint between left and right hip) that may be chronic, and subtle lucency in the right superior sacrum which may represent a nondisplaced fracture. The exam indicated an MRI (magnetic resonance imaging) should be considered for further evaluation. A review of a nursing progress note, dated 03/06/2021 at 4:22 PM, revealed the resident had transferred several times from the bed to the wheelchair with staff assistance, but still complained of pain that increased during transfers even after pain medication had been administered. The resident remained very guarded of the left leg due to pain and was not putting weight on the left leg when transferring. A review of a nursing progress note, dated 03/07/2021 at 5:48 PM, revealed the resident had been up in wheelchair two times but had increased pain to the left leg during transfers. Swelling to the left leg was noted and the resident indicated the pain medication helped, but the pain never completely went away. A review of a nursing progress note, dated 03/11/2021 at 9:24 PM, revealed, orders given to x-ray left femur. A review of an X-ray, dated 03/11/2021, revealed an acute fracture to the distal left femur (thigh bone just above the knee joint). Resident #30's care plan was not updated following the fall that caused the left femur fracture. A review of a fall incident report, dated 03/16/2021, revealed the resident was yelling, and staff went to the resident's room and saw the resident sitting on the floor. When staff entered the room, the resident was sitting on the floor beside the bed with blood in their hair. The resident stated they were trying to get something from the closet. The resident had a 6 cm x 1.1 cm cut to the head. The physician was notified and an order was received to send the resident out to the ER. A further review revealed no causal factors related to the fall or appropriate interventions were identified. The care plan was not updated following this fall. A review of a nursing progress note, dated 03/11/2021 at 11:08 PM, revealed the nurse from the ER called to let the staff know that the resident was returning to the facility, and the CT (computerized tomography) scan was clear. The nurse from the ER informed the staff that the resident had six to seven sutures to the wound. A review of a fall incident report, dated 03/29/2021, revealed the resident had an un-witnessed fall. Staff observed the resident lying on the floor in the hallway right outside the resident's room. The resident was lying on their back, with a wheelchair by the foot of the bed in the resident's room. No injuries were noted. A further review revealed no causal factors related to the fall or appropriate interventions were identified. The care plan was not updated following this fall. A review of a fall incident report, dated 05/12/2021, revealed staff found the resident on the floor beside the bed. The resident stated they slid out of bed while attempting to transfer to the wheelchair. No injuries were noted. A further review revealed no causal factors related to the fall or appropriate interventions were identified. The care plan was not updated following this fall. A review of a fall incident report, dated 07/04/2021, revealed staff witnessed another resident grab the handles of Resident #30's wheelchair, lifted it and dumped the resident on the floor. The resident landed on their left hip and left elbow and hit their head on the door that went to the courtyard. No injuries were noted. A further review revealed no causal factors related to the fall or appropriate interventions were identified. The care plan was not updated following this fall. A review of a fall incident report, dated 09/02/2021, revealed staff heard a loud thud and observed the resident sitting on the floor. The resident stated they were trying to get up from the wheelchair and the wheelchair moved. No injuries were noted. A further review revealed no causal factors related to the fall or appropriate interventions were identified. The care plan was not updated following this fall. A review of a fall incident report, dated 09/10/2021, revealed staff observed the resident walk behind their wheelchair and start to fall. The resident assisted themself down by grabbing onto the side rails on the wall. No injuries were noted. A further review revealed no causal factors related to the fall or appropriate interventions were identified. The care plan was not updated following this fall. A review of a fall incident report, dated 09/17/2021, revealed the resident reported standing up out of the wheelchair and lost their balance. The resident was resistive when staff tried to assist. No injuries were noted. A further review revealed no causal factors related to the fall or appropriate interventions were identified. The care plan was not updated following this fall. A review of a fall incident report, dated 10/10/2021, revealed the resident reported standing up out of bed and fell on their buttocks. No injuries were noted. A further review revealed no causal factors related to the fall or appropriate interventions were identified. The care plan was not updated following this fall. A review of a fall incident report, dated 10/22/2021, revealed staff observed the resident down the hallway, sitting on the floor in front of their room. No injuries were noted. A further review revealed no causal factors related to the fall or appropriate interventions were identified. The care plan was not updated following this fall. A review of a fall incident report, dated 11/24/2021, revealed staff heard a noise in the hallway and found the resident in front of their wheelchair, lying on their back. No injuries were noted. A further review revealed no causal factors related to the fall or appropriate interventions were identified. The care plan was not updated following this fall. A review of a fall incident report, dated 12/18/2021, revealed staff heard a noise in the hallway and found the resident in front of their wheelchair, lying on their back in front of another resident's room. No injuries were noted. A further review revealed no causal factors related to the fall or appropriate interventions were identified. The care plan was not updated following this fall. A review of a fall incident report, dated 01/24/2022, revealed the resident was at the nurses' station and reported that the resident fell and hit their head. A 3 cm x 5 cm nodule was observed to the left side of the back of the resident's head. No staff reported hearing any sounds prior. A further review revealed no causal factors related to the fall or appropriate interventions were identified. The care plan was not updated following this fall. A review of a fall incident report, dated 01/29/2021, revealed staff found the resident on the floor in the hallway of the unit. Their wheelchair was in the unit by the exit door leading to the hallway. A small hematoma was noted to the back of the head. A further review revealed no causal factors related to the fall or appropriate interventions were identified. The care plan was not updated following this fall. 2. A review of the face sheet revealed the facility admitted Resident #25 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the discharge Minimum Data Set (MDS), dated [DATE], indicated Resident #25 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated severe cognitive impairment. Resident #25 required extensive assistance of two staff with bed mobility, dressing, and toileting. Resident #25 required limited assistance of one person with eating. A review of the care plan, initiated on 12/30/2021, revealed the resident was at moderate risk for falls. Further review revealed interventions included to anticipate and meet resident needs, be sure call light was within reach and encourage resident to use it for assistance, educate resident/family/caregivers about safety reminders and what to do when a fall occurs, and follow facility fall protocol. The resident did not have a care plan for falls prior to 12/30/2021 and there had been no updates or revisions since the care plan was implemented on 12/30/2021. A review of the falls risk assessment, completed on 07/16/2021, revealed the resident scored a 16, which meant the resident was considered a high fall risk. A review of a fall incident report, dated 08/28/2021, revealed the resident was found sitting on the floor in their room with their back up against the bed with an abrasion to the left upper back, shoulder, and left and right knee. A further review revealed no causal factors related to the fall or appropriate interventions were identified. A care plan was not implemented or revised following this fall. A review of a fall incident report, dated 09/21/2021, revealed the resident was found sitting near their bed, their brief was removed and feces was on the floor. There was blood on the right side of the resident who was facing the wall. The resident had large bruising to the right elbow and a skin tear. A further review revealed no causal factors related to the fall or appropriate interventions were identified. A care plan was not implemented or revised following this fall. A review of a fall incident report, dated 11/05/2021, revealed the resident was found lying on the floor mat next to the bed. No injuries were noted. A further review revealed no causal factors related to the fall or appropriate interventions were identified. A care plan was not implemented or revised following this fall. A review of a fall incident report, dated 12/07/2021, revealed the resident was observed sitting in a wheelchair by the double doors on the dementia unit. Staff heard a noise and observed the resident on the floor with a right elbow skin tear. A further review revealed no causal factors related to the fall or appropriate interventions were identified. A care plan was not implemented or revised following this fall. A review of a fall incident report, dated 12/10/2021, revealed the resident was observed on their knees on the floor in their room, up against the bed. No injuries were noted. A further review revealed no causal factors related to the fall or appropriate interventions were identified. A care plan was not implemented or revised following this fall. A review of a fall incident report, dated 12/27/2021, revealed the resident was at the nurses' station for better observation. Staff heard a loud noise and observed the resident sitting on the floor with their back to the resident's door. No injuries were noted. A further review revealed no causal factors related to the fall or appropriate interventions were identified. A care plan was not updated following this fall. A review of a fall incident report, dated 12/28/2021, revealed the resident was at the nurses' station for closer observation, sitting in a wheelchair, and then the resident suddenly fell out of the wheelchair and landed on their left side on the floor. A skin tear to the left elbow and a bruise and abrasion to the left temple were noted. A further review revealed no causal factors related to the fall or appropriate interventions were identified. A care plan was not updated following this fall. A review of a fall incident report, dated 01/17/2022, revealed the resident was observed on the floor mat beside the bed, in an upright position. No injuries were noted. A further review revealed no causal factors related to the fall or appropriate interventions were identified. The care plan was not updated following this fall. A review of a fall incident report, dated 01/23/2022, revealed staff heard a loud noise, and the resident was observed on the floor in their room, with their head slightly under the bed. The resident had a 4 cm (centimeter) x 4 cm hematoma to the front left side of the forehead. A further review revealed no causal factors related to the fall or appropriate interventions were identified. The care plan was not updated following this fall. A review of a fall incident report, dated 01/26/2021, revealed the resident was found on the floor with the wheelchair in their hands when staff came down hallway. The resident had a .2 cm x .2 cm and 1 cm x 1 cm scratch to the top of the head. A further review revealed no causal factors related to the fall or appropriate interventions were identified. The care plan was not updated following this fall. 3. A review of the face sheet revealed the facility admitted Resident #11 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the discharge Minimum Data Set (MDS), dated [DATE], indicated that Resident #11 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated moderate cognitive impairment. Resident #11 required limited assistance of one staff with bed mobility and toileting and supervision with set-up for transfers and eating. A review of the care plan, initiated on 11/05/2021, revealed the resident was an elopement risk. Further review revealed interventions included placement on the secure unit, provide structured activities, distract resident from wandering by offering pleasant diversions, and identify pattern of wandering. Further review revealed there had been no updates to the care plan since it was implemented on 11/05/2021. A review of a facility investigation, dated 01/10/2022, revealed Resident #11 left the facility after breakfast on 01/10/2022 through a window across the hall from the resident's room. The administrator was notified that the resident could not be located around 10:00 AM. Staff searched the facility and surrounding areas and contacted law enforcement. The facility became aware that police had been contacted about a person seen falling that fit the description of Resident #11. Facility staff learned that Resident #11 had been treated at a local hospital and taken by police to an unknown location. Staff were able to identify the resident's location with assistance from the resident's family member. With law enforcement's assistance, they made contact with the resident and safely returned the resident to the facility around 11:00 AM on 01/10/2022. 4. A review of the Minimum Data Set (MDS) assessment, dated 10/19/2021, revealed Resident #3's cognitive status was not assessed. A further review of the MDS indicated the resident required extensive to total assistance of one to two staff for Activities of Daily Living (ADLs). The resident was always incontinent of bowel and bladder. The MDS was incorrectly coded, indicating the resident had not had any falls since the previous assessment. A review of a Weekly Nursing Summary, dated 02/02/2022, indicated Resident #3's cognitive status was severely impaired, and the resident required the use of a full body lift (Hoyer) for all transfers. A review of the comprehensive care plan, initiated 01/23/2021, indicated Resident #3 was a risk for falls related to gait/balance problems, paralysis, and was unaware of safety needs with a goal not to sustain serious injury. Interventions included: -Anticipate and meet the resident's needs. -Follow facility fall protocol. -Physical Therapy (PT) evaluate and treat as ordered or as needed (PRN). A further review of the comprehensive care plan indicated it was updated on 03/10/2021 to include Resident #3 had a behavior problem related to sliding out of the bed to play with electrical cords and climbing out of bed. Interventions included: -Anticipate and meet the resident's needs. -Monitor behavior episodes and attempt to determine underlying cause. A review of Resident #3's electronic health record (EHR) on 02/01/2022 revealed Resident #3 had twenty-eight (28) documented falls from February 2021 through December 2021, seventeen (17) from 08/09/2021 through 12/21/2021. After a fall on 08/11/2021, the care plan was updated to include the resident had a fall trying to turn the air conditioner off and fell over the mat. Interventions included: -Call light in reach at all times. -Family and primary care physician (PCP) notified of fall. -Therapy referral if indicated. -Vital signs per protocol. A further review of the care plan indicated it was updated with the date of each fall only, and no new interventions were initiated. 5. A review of the face sheet indicated the facility admitted Resident #19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #19 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12 out of 15. The MDS indicated the resident had no behaviors of rejecting care. A further review of the MDS indicated Resident #19 required supervision with set up or one-person assist for bed mobility and transfers and moderate assist of one person for dressing, toilet use, and personal hygiene. The bathing activity did not occur during the assessment period. A review of a progress note, dated 12/25/2021, indicated Resident #19 refused their shower after being asked more than once. A review of bathing sheets from December 2021 through February 2022 indicated Resident #19 refused shower opportunities on multiple occasions. A review of the resident's care plan, dated 03/29/2017, did not indicate the resident refused showers or provide interventions to address the resident's refusals. An interview with Nursing Assistant (NA) B on 02/03/2022 at 2:35 PM revealed she was not sure what other interventions were in place for the residents, except for redirection. NA B also stated that she was not sure of what was on the resident's care plan since she did not have access to them. An interview on 02/03/2022 at 3:09 PM with Registered Nurse (RN) B revealed she did not know who was responsible for identifying interventions or updating the care plan. RN B stated she was not even sure who all had access to care plans or if CNA staff could access them. RN B stated that staff would check on Resident #30 more often, but she was not sure what other interventions were care planned for the resident. An interview with Certified Nursing Assistant (CNA) C on 02/04/2022 at 1:24 PM revealed she was not aware of other interventions in place for fall prevention besides redirection and she had never been a part of a process to identify appropriate interventions for residents who were fall risks. CNA C stated that only nurses had access to the care plans and could see what interventions were listed. An interview on 02/04/2022 at 1:46 PM with RN A revealed she was not sure who was responsible for updating the care plan. RN A stated that staff tried to remind Resident #30 to stay in their wheelchair and ask staff to help assist with transfers and that Resident #25 had a fall mat and staff tried to remind them to ask for staff assistance. RN A stated the facility did not use restraints so there were not a lot of other options but admitted that reminding residents who had cognitive deficits was not effective or appropriate. An interview with NA C on 02/04/2022 at 9:15 AM revealed she was not sure what a care plan was because she had never seen one. NA C stated that staff reminded residents on the dementia unit who were a fall risk to ask and wait for assistance before attempting to transfer or get up unassisted. NA C also stated that due to the residents' cognitive deficits, they were not able to remember what staff reminded or told them to do, and it was not an effective fall prevention. NA C stated she was not sure why NA or CNA staff could not access the care plans and stated, That's a good question, when asked. An interview on 02/04/2022 at 6:30 PM with LVN H revealed she thought the ADON and/or DON identified root cause and updated the care plan with new interventions. LVN H stated that CNA staff could not access the care plans, but she was not sure why, but agreed it would be beneficial since CNA staff provided the most direct care to residents. An interview on 02/05/2022 at 9:01 AM with the ADON revealed she was not sure who identified root cause and long-term interventions and knew the DON had their own process, but she was not sure what that process consisted of. The ADON stated she thought the MDS coordinator updated the care plan, but she was not exactly sure who was responsible for updating the care plans. An interview on 02/08/2022 at 1:59 PM with NA D revealed that Resident #25 had a fall mat and that she did not know if Resident #30 was a fall risk. NA D stated she did not know what falls interventions were in place for either resident. NA D stated she did not know what a care plan was, and she had never seen one and that she had never been shown where or how to access one. An interview on 02/09/2022 at 5:37 PM with the Director of Nursing (DON) revealed she reviewed care plans, but the MDS Coordinator was responsible for updating the care plan. The DON stated that she felt it was an appropriate fall intervention to educate and remind residents that have cognitive deficits and that staff reminded them every day. During an interview on 02/11/2022 at 1:00 PM, the Medical Director (MD) stated fall prevention was the number one thing to be discussed for all residents during the MD's monthly visits to the facility. The MD stated interventions to prevent falls changed as resident conditions changed. The MD stated the facility reported falls to the MD via fax and was aware of all falls and did not see a problem with the process in place. An interview on 02/12/2022 at 9:50 AM with MDS Coordinator revealed it was the MDS coordinator's role to initiate and evaluate care plans and update them as needed. The MDS Coordinator stated she was new to that role and would not start training until 02/14/2022. The MDS Coordinator stated that she thought all staff that provided care to residents should have access to them. The MDS Coordinator stated that after a fall occurred care plans should be evaluated for appropriate interventions and current interventions and new ones should be explored. The MDS Coordinator agreed that residents with cognitive deficits would not benefit from reminding or education since they would not retain the information and it would not assist with prevention. An interview on 02/12/2022 at 10:54 AM with the Administrator revealed he expected that care plans should be updated after a change in condition such as falls or elopements, and that they should be reviewed to ensure current interventions were appropriate and updated if new ones were identified. 6. A review of Resident #28's face sheet indicated the facility admitted the resident on 06/10/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #28's quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident had short-term and long-term memory problems and was severely cognitively impaired. The MDS indicated the resident's Brief Interview for Mental Status (BIMS) was not done. A review of Resident #28's comprehensive care plan, dated 12/13/2021, indicated the resident was at moderate risk for falls and had seven falls from 08/23/2021 to 12/04/2021. The interventions in place were created on 07/13/2021 and were anticipated to meet the resident's needs, follow facility protocol, and for Physical Therapy to evaluate and treat as ordered and as needed (PRN). A review of a facility document titled, Incidents by incident type, dated 02/02/2022, indicated Resident #28 had fall incidents on 08/23/2021, 10/13/2021, 10/25/2021, 11/26/2021 (with injury), 11/29/2021, and 12/04/2021. A review of Resident #28's post fall risk assessments on 08/23/2021, 10/13/2022, and on 10/25/2022 indicated the resident was at high risk for falls. The assessment indicated the resident had intermittent confusion and required assistance with elimination. A review of Resident #28's nurses notes, dated 08/23/2021 at 4:00 PM, indicated the resident was sitting in a recliner, leaned back too far, and tipped it over. The resident hit their head. A review of Resident #28's fall nurses notes, dated 08/23/2021 at 5:17 PM, indicated the resident had an unwitnessed fall in the activity room. The notes indicated the resident was sitting in the pink recliner, leaned too far back, and tipped the chair over. The notes indicated a floor mat and scoop mattress were interventions to be put in place. A review of Resident #28's comprehensive care plan revealed no interventions for falls were updated after the fall incident on 08/23/2021. The care plan's last date of update was 07/13/2021 for interventions. A review of Resident #28's fall nurses notes, dated 09/12/2021 at 6:50 PM, indicated the resident had an unwitnessed fall in the dining room. The notes indicated the resident was sitting in the pink recliner, leaned too far back, and tipped the chair over. The notes indicated a floor mat and a low bed were interventions to be put in place. A review of Resident #28's comprehensive care plan revealed no interventions for falls were updated after the fall incident on 09/12/2021. The care plan's last date of update was 07/13/2021 for interventions. A review of Resident #28's fall nurses notes, dated 10/26/2021 at 12:14 AM, indicated the resident had an unwitnessed fall in the dining room. The notes indicated the resident was sitting in the pink recliner, leaned too far back, and tipped the chair over. The notes indicated a floor mat and a low bed were interventions to be put in place. A review of Resident #28's comprehensive care plan revealed no interventions for falls were updated after the fall incident on 10/26/2021. The care plan's last date of update was 07/13/2021 for interventions. A review of Resident #28's fall nurse's notes, dated 11/26/2021 at 6:49 PM, indicated the resident had an unwitnessed fall and obtained an abrasion to the back of the head measuring 1cm x 0.5 cm. The notes indicated a floor mat would be placed in the resident's room. A review of Resident #28's comprehensive care plan revealed no interventions for falls were updated after the fall incident on 11/26/2021. The care plan's last date of update was 07/13/2021 for interventions. A review of Resident #28's nurses notes, dated 11/29/2021 at 10:50 PM, indicated, This nurse noted on monitor [Resident #28 was] not in bed. The resident [was laying on the mat] on [their] right side on [the] floor. The notes did not reveal the details of the fall. The notes indicated a floor mat and a low bed were interventions to be put in place. A review of Resident #28's comprehensive care plan revealed no interventions for falls were updated after the fall incident on 11/29/2021. The care plan's last date of update was 07/13/2021 for interventions. A review of Resident #28's nurses notes, dated 12/04/2021 at 5:35 PM, indicated the resident fell trying to transfer themself from the wheelchair to the dining room chair. The notes indicated the fall was witnessed by another resident. The notes indicated the resident was not able to recall what actions led up to the fall. The notes indicated The Director of Nursing (DON), family member and physician were notified of the fall incident. A review of Resident #28's comprehensive care plan revealed no interventions for falls were updated after the fall incident on 12/04/2021. The care plan's last date of update was 07/13/2021 for interventions. A review of Resident #28's fall risk assessments post falls on 11/26/2021, 11/29/2021, and 12/04/2021 revealed no post-fall assessments were done. During an interview on 02/03/[TRUNCATED]

Based on interviews and record reviews, the facility failed to assess the resident population and document a facility-wide assessment to identify the resident population residing in the facility or what competencies, resources, or skills were needed to care for all 42 residents. Findings included: A review of the facility's policy titled, Facility Assessment, not dated, indicated, The facility assessment is a complete review of internal human and physical resources required by the facility to care for residents competently during day to day and emergency operations. The facility assessment identifies our capabilities as a skilled nursing services provider. The facility assessment will be the basis for surveyors to ascertain whether you are prepared to competently take care of the population you have identified that you serve. The policy indicated, Facility must review and update assessment annually or when modification are warranted. During an interview on 02/01/2022 at 8:30 AM, the Administrator was not sure what a facility assessment was and stated he had never completed one for the facility. The Administrator stated he would have to look for a copy of an old facility assessment and would attempt to update the facility assessment. A review of the facility assessment, dated 02/28/2020 (no time), revealed the facility assessment had not been updated since 02/28/2020. The table of contents for the facility assessment dated [DATE] was kept in a tab of a binder and had no other documents attached (only one page: table of contents). The next tab in the binder had the facility's policy titled, facility assessment and did not have the facility name or date or any facility-specific information. During an interview on 02/06/2022 at 11:00 AM, the Administrator, CEO, and COO reviewed the facility assessment dated [DATE]. The administrator stated the purpose of a facility assessment was to identify the resident population and what capabilities the facility had to care for the residents, what equipment was needed, and to establish a risk management plan. The CEO stated the purpose of the facility assessment was to know the type of residents in the facility and identify competency and training needs for all staff caring for the residents. The CEO stated the facility assessment needed to be updated annually or as needed. The COO asked the Administrator if he had updated the facility assessment since 02/28/2020, and the Administrator stated no, he had not. The Administrator stated he had not completed a facility assessment and did not know how to complete one. The CEO and COO reviewed the facility assessment provided by the administrator and confirmed the table of contents was the only part of the facility assessment that was signed and dated 02/28/2020. The CEO confirmed the facility assessment policy did not have the name of the facility or a date to indicate when the assessment had been done. The CEO confirmed the last facility assessment was done on 02/28/2020 but only the table of contents was able to be located. The CEO and COO stated if the facility had an updated facility assessment in place, the current immediate jeopardy deficiencies as of 02/05/2022 at 9:15 AM for QA, QAPI, Abuse, Accidents and hazards, and the unnecessary use of [CONDITION(S)] medication could have been prevented and further issues of immediate jeopardy would be prevented. During an interview on 02/09/2022 at 6:16 PM, the COO stated the governing body oversaw the administration in the facility by visiting the facility monthly, and that with certain things such as repeated falls, elopements, and abuse it was the administrator's responsibility to notify the governing body (CEO and COO). The COO stated that had obviously not been done because the facility administration was not identifying issues, so calls were not being made to the governing body. The COO stated it was important for administration to notify the governing body of all with the potential to harm residents, because that could que the governing body to a systemic failure. The COO stated not having an up-to-date facility assessment and the lack of communication and action by the facility administration had caused systemic issues. The COO stated the Administrator had a checklist provided which provided guidance on when to contact the governing body and covered all care areas. The COO stated the Administrator had obviously not been utilizing the checklist. Texas Administrative Code (TAC) S554.1931, Tag 1982. This requirement is not met as evidenced by: For evidence of violation refer to CMS Form 2567 dated 02/13/2022, F838.

Based on observations, interviews, and record reviews, the facility failed to ensure 3 (Residents #11, #12 and #20) of 3 sampled residents reviewed with dementia received the appropriate treatment and services to attain and/or maintain their highest practicable physical, mental, and psychosocial well-being when the facility did not develop individualized interventions and implement person centered care plans to address a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #12 with [CONDITION(S)] medications against their will or knowledge. The facility also failed to re-evaluate the [CONDITION(S)] medication use for Resident #20, who had a dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Findings included: A policy was requested from the facility, but the Director of Nursing (DON) stated the facility did not have a specific policy addressing providing care for residents diagnosed with dementia. 1. A review of the face sheet indicated Resident #12 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 01/28/2022, indicated Resident #12 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of seven out of 15 and no documented behaviors including refusing care. Further review of the MDS indicated the resident required supervision to limited assistance of one person for their Activities of Daily Living (ADLs). The resident received antipsychotic and antidepressant medication seven out of seven days during the assessment period. A review of the care plan dated 08/12/2021 indicated Resident #12 was at risk for decline related to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included: -Keep the family and the primary care physician (PCP) well informed of any problems. -Refer to therapy if indicated to help slow the progression. -Staff to allow time for the resident to complete the task. -Staff to give lots of TLC (tender, loving, care) and encourage the resident to do as much as possible for themselves to maintain their independence. A further review of the care plan dated 11/04/2021 indicated the resident was an elopement risk/wanderer as evidenced by impaired safety awareness, wandering aimlessly. Resident #12 lives on the secure unit. The resident also had a potential mood problem. Interventions included: -Assess for fall risk. -Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. -Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. -Administer medication as ordered. Monitor/document for side effects and effectiveness. -Assist in developing and provide the resident with a program of activities that is meaningful and of interest. Encourage and provide opportunities for exercise and physical activity. -Assist resident to identify strengths, positive coping skills and reinforce these. -Behavioral health consults as needed. -Monitor/record mood to determine if problems seem to be related to external causes. -Monitor/record/report to the physician as needed changes in mood patterns and risk for harm to self or others. No evidence indicated these interventions were being carried out. A review of progress notes from August 2021 through February 2022 revealed Resident #12 had multiple behaviors related to being placed in the secure unit of the facility and wanting to leave. There is no documentation of the facility attempting to treat the resident's behaviors with non-pharmacological interventions prior to administering a [CONDITION(S)] medication including [MEDICATION(S)] ([MEDICATION(S)], an antianxiety) and intramuscular injection (IM) [MEDICATION(S)] (an antipsychotic). A review of progress notes dated 09/11/2021 written by Registered Nurse (RN) B indicated Resident #12 was agitated, refusing their medications, refusing to eat and was disruptive. Notes indicated the physician ordered a shot to help calm them down and [MEDICATION(S)] 5 milligrams (mg) was given IM in the left hip. The notes indicated the resident was upset about the situation after receiving the injection. A review of the record revealed no documentation of non-pharmacological interventions being attempted in response to Resident #12's behaviors prior to the [MEDICATION(S)] being administered. A review of progress notes dated 11/03/2021 written by Licensed Vocational Nurse (LVN) E at 5:50 AM indicated Resident #12 wanted to call their family but was redirected several times back to their room and was told they had to wait until morning. The notes indicated the resident became combative by hitting, kicking, spitting, and scratching the staff so LVN E called the family and got consent to give the resident an injection. The notes indicated LVN E, and the Certified Nurse Aide (CNA) held the resident down to give the IM injection. The note indicated the resident continued to wander around the secure unit yelling, trying to call 911 and going into other resident's rooms, waking them up. (The family was called for consent to give a medication but was not called to prevent the resident from getting upset). A review of the record revealed no documentation of non-pharmacological interventions being attempted in response to Resident #12's behaviors, such as allowing the resident to talk to family, prior to the [MEDICATION(S)] being administered. A review of progress notes dated 11/12/2021 written by LVN F indicated Resident #12 was agitated with staff and family, making threatening statements to family, and wanting to leave the facility. The notes indicated the resident refused to take [MEDICATION(S)] ([MEDICATION(S)]) and stated they were not taking any more medications and would rather be dead than take anymore medications. The notes indicated the resident was given a [MEDICATION(S)] injection in the left arm A review of the record revealed no documentation of non-pharmacological interventions being attempted in response to Resident #12's behaviors prior to the [MEDICATION(S)] being administered. A further review of progress notes dated 11/25/2021 at 3:40 PM indicated the resident became upset, threatening family, wanting the police called and was not able to be redirected. The note indicated RN B told the resident if they did not settle down, they would be getting a shot, which upset the resident more. At 4:40 PM the notes indicated the resident was given [MEDICATION(S)] 5 mg IM in the left hip with assistance of staff from the other wing. A review of the record revealed no documentation of non-pharmacological interventions being attempted in response to Resident #12's behaviors prior to the [MEDICATION(S)] being administered. A review of progress notes dated 11/30/2021 by RN B indicated Resident #12 was medicated with [MEDICATION(S)] before the resident goes off because once the resident was upset, they would not take any of their pills. The note indicated the [MEDICATION(S)] was put in the resident's eggs and they ate all of them even though the resident took all their scheduled medications without any problem. A review of Resident #12's record revealed no activity assessment had been completed for the resident. There was no documentation of Resident #12 participating in activities. Observations made of Resident #12 throughout the survey revealed the resident was lying on the bed or sitting in a chair in their room in the dark most of the time. The resident was not seen participating in any type of activity. An observation on 06/06/2022 at 3:28 PM found Resident #12 in their room with the lights off sitting on the edge of the bed. An observation on 02/07/2022 at 10:13 AM found Resident #12 lying on the bed in their room with the lights off. An observation on 02/08/2022 at 7:44 AM found Resident #12 lying on their bed in their room and stated they were waiting for breakfast. At 2:27 PM the resident was observed sitting on the edge of the bed in their room with the lights off. An observation on 02/10/2022 at 1:40 PM found Resident #12 lying in the bed in their room. The resident stated they were doing fine that day. During an interview with CNA G on 02/04/2022 at 6:30 PM she stated she usually worked from 6:00 PM until 6:00 AM on the secure unit. She said there are never any structured activities for the residents on the unit when she was working. She said it was usually just the nurse and the CNA on the unit and they did not have time to try and do activities with the residents. She stated she had received dementia training on the computer but nothing specific for their resident's. CNA G stated Resident #12 usually stayed in her room with the door closed. During an interview with the Activity Director (AD) on 02/06/2022 at 3:04 PM she stated she did not keep a log of resident's participation in activities. She said this was not documented. She stated doing activities with residents with dementia was very hard since they have their own mindset of what they want to do. The AD stated she was not sure why Resident #12 did not have an activity assessment. She stated Resident #12 was usually in her room and did not participate when she did an activity in the secure unit. During an interview with RN B on 02/08/2022 at 12:35 PM RN B stated if the resident wouldn't take their medications or spit their medications out, she would hide the medication in their food. RN B stated sometimes you had to be ingenious on how to give it. RN B stated she usually mixed it in something sweet. RN B stated they would attempt three to four times to get the resident to take their medications over a one-to-two-hours, reapproaching them every 30 minutes because the residents usually have forgotten by that time. RN B stated when Resident #12 starts having behavior issues, such as wanting to call their family and cuss them out, she would hide the [MEDICATION(S)] in something the resident eats. RN B stated they had to give Resident #12 [MEDICATION(S)] a couple of times after the resident first admitted to the facility because the resident was demanding to call and threatening the family on the phone, beating on the door, knocking over everything on the over bed table, threw a table, and wanting to call the police. RN B stated she got another staff member to hold the resident, a strong CNA, because she would not be able to do it on her own. RN B stated she could not recall what CNA assisted her. RN B stated she had never heard of sending a resident out of the facility for emergency psych services. RN B stated Resident #12 was adjusting well to the facility now and stayed in her room most of the time. During an interview with Licensed Vocational Nurse (LVN) D on 02/10/2022 at 3:04 PM she stated there was only one person in the activity department and she tried to do activities with the residents, but it was limited. She stated there was no activity staff on the weekends. She stated an activity calendar should be in each resident's room. After looking in a few resident's rooms, LVN D confirmed the residents did not have activity calendars in their rooms. During an interview with LVN G on 02/10/2022 at 2:11 PM he stated he had not seen activities being done consistently in the secure unit. He said the activity staff, or the CNA would occasionally take a few residents out to the main dining area when they were having a birthday or holiday party. LVN G stated they received dementia training on the computer. LVN G stated if there were more consistent activities for the residents on the secure unit there might be less behaviors. LVN G stated Resident #12 had a hard time adjusting to the facility and required [MEDICATION(S)] frequently to keep them calm but they were now doing well and did not require it near as often. 2. A review of the face sheet indicated the facility admitted Resident #20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #20 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of two out of 15. The resident had the behavior of inattention that fluctuated. A further review of the MDS indicated the resident required extensive assistance of two people for their Activities of Daily Living (ADLs). The resident received antipsychotic and antianxiety medication seven out of seven days during the assessment period. The MDS indicated the resident was receiving hospice care. The care plan initiated 01/18/2015 and last revised 05/07/2015 indicated the resident had impaired cognitive function or impaired thought processes related to Alzheimer's dementia. The care plan indicated the resident had little or no activity involvement related to physical limitations. Interventions included: -Administer medications per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Report abnormal finding to the physician. -Monitor/document/report to physician any changes in cognitive function. -Identify yourself at each interaction. -Face resident when speaking and make eye contact. -Reduce any distractions, ensure the resident understands, use consistent, simple, directive sentences. Repeat information as needed. Explain all procedures with terms and gestures the resident can understand. -Stop and return if the resident becomes agitated. -Engage in simple, structured activities that avoid overly demanding tasks. -Provide instructions to resident using clear voice and simple sentences. Repeat as needed. Allow resident time to respond. -Keep routine consistent and try to provide consistent care gives as much as possible to decrease confusion. -Provide opportunities for resident to make simple choices with ADLs. Encourage participation. -Resident needs supervision/assistance with all decision making. -Provide a program of activities that accommodated the resident's abilities. -Provide an environment, visible clocks, a calendar, low-glare light, consistence care routines, familiar objects and reduced sensory noise. -The resident needs assistance/escort to activity functions. A further review of the care plan initiated 01/18/2015 and last revised 02/05/2020 indicated Resident #20 used [CONDITION(S)] medications related to depression and a delusional disorder. It indicated the last gradual dose reduction (GDR) for [MEDICATION(S)] (antipsychotic) was 12/24/2019 and the date for the last GDR for [MEDICATION(S)] was not listed. Interventions included: -Administer medications as ordered. Monitor/document for side effects and effectiveness. -Evaluate effectiveness and side effects of medications routine for possible decrease/elimination of [CONDITION(S)] medications. -Monitor/record/report to physician as needed (PRN) side effects and adverse reactions of psychoactive medications. -Medication regime to be routinely reviewed by the pharmacist with all recommendations, including suggested reductions, to be forwarded on to the physician. -Monitor pharmacist drug regime review for identification of potential drug interactions. -Monitor interaction of resident with others for appropriateness. -Monitor residents bowel elimination pattern. A review of Resident #20's February 2022 Computerized Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)], 1 milligram (mg), one tablet by mouth twice a day, ordered on 08/16/2020, for restlessness/picking related to major depressive disorder, recurrent, severe with psychotic symptoms. A review of progress notes from 10/01/2021 through 02/01/2022 revealed no documentation of Resident #20 having behaviors other than the resident picking or scratching their skin on two separate occasions. A review of the documentation for generalized behaviors on the Medication Administration Records (MAR) from November through January indicated the resident did not have any behaviors other than picking and scratching at skin on two separate occasions. Observations of Resident #20 throughout the survey revealed the resident was either lying in bed or sitting back in a Geri-chair in their room. The resident was not engaged in any type of activities. Observations include: -An observation on 02/01/2022 at 1:14 PM, found Resident #20 leaning back in a Geri-chair in their room with the lights off and the blinds closed. - An observation on 02/02/2022 at 10:42 AM, found Resident #20 leaning back in a Geri-chair in room with lights off. The blinds were open, but the roommate's curtain was pulled making the room dark. -An observation on 02/04/2022 at 12:26 PM, found Resident #20 being assisted with lunch. -A observation on 02/06/2022 at 4:16 PM, found Resident #20 was lying in bed with the lights off. -An observation on 02/08/2022 at 1:39 PM, found Resident #20 leaning back in a Geri-chair with the lights on and the blinds open. A review of the Quarterly Activity assessment dated [DATE] indicated the resident participated in activities three to five times a week and participated in independent activities of choice. The assessment indicated the resident required assistance to attend activities and was an active participant with assistance. The assessment indicated the resident preferred to be with people, made friends easily but rarely initiated conversations. The assessment indicated the resident preferred to stay in their room, enjoyed small groups, communicated nonverbally and was unable to make needs known. The assessment indicated the resident was dependent on others for wheelchair transport. The resident had a short attention span, was forgetful and required reminders/cues. During an interview with CNA G on 02/04/2022 at 6:30 PM she stated she usually worked from 6:00 PM until 6:00 AM on the secure unit. She said there are never any structured activities for the residents on the unit when she was working. She said it was usually just the nurse and the CNA on the unit and they did not have time to try and do activities with the residents. She stated she had received dementia training on the computer but nothing specific for their resident's. CNA G stated Resident #20 was not on the secure unit, and she had not cared for Resident #20 and could not comment on his behaviors. CNA G stated Resident #12 usually stayed in her room with the door closed. During an interview with the Activity Director (AD) on 02/06/2022 at 3:04 PM she stated she did not keep a log of resident's participation in activities. The AD stated Resident #20 did not participate in group activities but had one-to-one visits in their room. She said this was not documented. She stated doing activities with residents with dementia was very hard since they have their own mindset of what they want to do. During an interview with RN B on 02/08/2022 at 12:35 PM RN B stated if the resident wouldn't take their medications or spit their medications out, she would hide the medication in their food. RN B stated sometimes you had to be ingenious on how to give it. RN B stated she usually mixed it in something sweet. RN B stated they would attempt three to four times to get the resident to take their medications over a one-to-two-hours, reapproaching them every 30 minutes because the residents usually have forgotten by that time. RN B stated she did not care for Resident #20 and could not comment on his behaviors. During an interview with Licensed Vocational Nurse (LVN) D on 02/10/2022 at 3:04 PM she stated there was only one person in the activity department and she tried to do activities with the residents, but it was limited. She stated there was no activity staff on the weekends. She stated an activity calendar should be in each resident's room. After looking in a few resident's rooms, LVN D confirmed the residents did not have activity calendars in their rooms. During an interview with LVN G on 02/10/2022 at 2:11 PM, he stated he had not seen activities being done consistently in the secure unit. He said the activity staff, or the CNA would occasionally take a few residents out to the main dining area when they were having a birthday or holiday party. LVN G stated they received dementia training on the computer. LVN G stated if there were more consistent activities for the residents on the secure unit there might be less behaviors. LVN G stated he had not cared for Resident #20 and could not comment on his behaviors. 3. A review of Resident #11's face sheet revealed the facility admitted Resident #11 on 11/02/2021 and the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/11/2022, the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the discharge Minimum Data Set (MDS), dated [DATE], indicated that Resident #11 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated moderate cognitive impairment. Resident #11 required limited assistance of one staff with bed mobility and toileting and supervision with set-up for transfers and eating. A review of the care plan, initiated on 11/15/2021, revealed the resident had impaired cognition/function or impaired thoughts related to dementia. Interventions included to administer medications as ordered, engage the resident in simple, structured activities that avoid overly demanding tasks, communicate with the resident/family/caregivers regarding residents' capabilities and needs, keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion, and review medications and record for possible causes of cognitive deficit. A review of the January 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The order directed staff to inject 5 mg intramuscularly every six hours for 14 days as needed for agitation. Further review revealed the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 02/03/2022 at 12:30 PM with Resident #11 revealed the resident told staff the resident did not want to take daily medications. Resident #11 stated, I told them to stop trying to feed me all that medicine. Resident #11 went on to say that staff held the resident's arms while another staff member injected the medication via a shot. Resident #11 stated they were not hitting staff but that they were attempting to back away from staff since staff were trying to force the resident to take the shot. An interview with Nursing Assistant (NA) B on 02/03/2022 at 2:35 PM revealed that on the morning of 01/17/2022 Resident #11 was mad at RN A and did not want to take the resident's medications. NA B stated after that she was at the nurse's station with RN A when RN A contacted the Assistant Director of Nursing (ADON) and stated that Resident #11 was refusing to take their daily scheduled medications. NA B stated that after RN A contacted the ADON, the ADON came along with Certified Nursing Assistant (CNA) C and spoke with Resident #11. NA B stated she did not know why the ADON got another CNA instead of her to go into Resident #11's room. NA B stated she could hear yelling coming from Resident #11's room after the ADON and CNA C went into Resident #11's room. The ADON and CNA C returned and stated Resident #11 agreed to a shot and that one was administered. An interview on 02/03/2022 at 3:09 PM with Registered Nurse (RN) B revealed if a resident refused their medications that staff should leave the resident alone for about thirty minutes and then re-approach to see if they were ready to take their medication at that time. RN B stated if the resident continued to refuse then staff should send a fax to the physician to make them aware and let the DON know. RN B stated when passing medications to residents, she tried providing the resident with the pills in a cup, but if the resident refused she would try to hide the pills in the resident's food. RN B stated she would put the pills in something the resident liked to eat and ask them to swallow and not to chew the food. RN B stated she tried to give a resident the opportunity to refuse three or four times before contacting the physician. RN B stated that she had not had any issues with Resident #11 and that she had never been aware of Resident #11 being combative. An interview with CNA C on 02/04/2022 at 1:24 PM revealed she was not working on the locked unit on the morning of 01/17/2022 but was asked by the ADON to come and be a witness to the ADON administering a shot to Resident #11. CNA C stated that she went into Resident #11's room along with the ADON and that the ADON asked Resident #11 if the resident would take the resident's pills or take a shot. Resident #11 agreed to take the shot and told the ADON, Hurry up and get it over with. CNA C stated that nobody held Resident #11 and that Resident #11 willingly took the shot. CNA C stated she left after that and did not know what occurred after that point. CNA C stated she did not remember receiving any training on how to handle residents' behaviors with dementia. CNA C stated she could not remember the last time she completed training related to dementia or how often staff completed it. An interview with RN A on 02/04/2022 at 2:04 PM revealed on the morning of 01/17/2022 she went into Resident #11's room and observed Resident #11 lying down in the bed on the resident's back, looking up. RN A stated she stood beside Resident #11's bed and asked the resident if she could take the resident's blood pressure and give the resident their morning medications. Resident #11 raised their arm and it contacted RN A's chest and the resident refused to take the medications. RN A stated she asked the resident again, and the resident became upset and refused again. RN A stated she left the resident's room and called and reported it to the ADON, who then came along with CNA C and went into Resident #11's room. RN A stated Resident #11 had never had an issue with NA B and did not know why the ADON took CNA C with her to administer the shot of Haldon instead of taking NA B. RN A stated that the ADON came out of the room and told her that Resident #11 agreed to the shot but not the pills. RN A thought that was unusual that Resident #11 was adamant about not taking any medications but agreed to the shot. RN A stated there had not been any further incidents with Resident #11 refusing medications. During an interview on 02/05/2022 at 9:01 AM, the ADON stated that on the morning of 01/17/2022 she was notified by RN A that Resident #11 was refusing to take their morning medication or have their vitals taken, and that Resident #11 swung at RN A but did not hit her hard. The ADON stated she went to the dementia unit (where the resident resided) and took Resident #11's medications with her and tried to talk to Resident #11 and reason with them. The ADON stated that Resident #11 refused to take their medication and then looked out the window and screamed. The ADON stated that she went to notify the physician, and he gave the order to give Resident #11 a PRN (as needed) [MEDICATION(S)] injection. The ADON stated that CNA C came into the dementia unit and asked the ADON if she wanted CNA C to go with her when she went to give the shot to Resident #11 and the ADON told her, Yes. The ADON stated she went back into Resident #11's room along with CNA C and asked the resident if they wanted to take their pills or take the shot. Resident #11 agreed to take the shot and allowed the ADON to administer it. The ADON stated that after Resident #11 received the shot they became combative again and tried to swing at the ADON, but she just exited the room. The ADON stated she got the [MEDICATION(S)] from the emergency kit that the facility had prior to the facility getting the Pyxis (a medication dispensing system). The ADON stated there was no documentation that the [MEDICATION(S)] was in the emergency kit or that she took it on 01/17/2022 to give to Resident #11. The ADON stated that it should have been indicated on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 02/09/2022 at 4:45 PM with Psychiatric Nurse Practitioner (PNP) revealed he thought [CONDITION(S)] medications should be used as a last resort. PNP stated [MEDICATION(S)] had a lot of side effects and that those should be weighed against the benefits when deciding to use. The PNP stated [MEDICATION(S)] contributed to swallowing issues and could increase the potential for falls. The PNP also stated that [MEDICATION(S)] was disorienting and was not ideal to use on a person who was already disoriented. The PNP also stated that using [MEDICATION(S)] on residents that had exit-seeking behaviors could be more harmful than good. An interview on 02/09/2022 at 5:37 PM with the Director of Nursing (DON) revealed she investigated the incident that occurred on 01/17/2022 when the ADON administered a PRN [MEDICATION(S)] injection to Resident #11. The DON completed the investigation on 02/05/2022. The DON stated she felt it was an unnecessary use of a [CONDITION(S)] medication and that Resident #11's behaviors did not warrant its use. A review of a facility investigation, dated 02/05/2022 related to a [MEDICATION(S)] incident on 01/17/2022, revealed it was Resident #11's right to refuse medication and that staff should have allowed the resident to fully calm down and attempt to give the medications again at a later time. The investigation indicated that giving someone an injection to calm them down when they were not outwardly acting out or displaying behaviors that would give rise to harming themselves or others is considered a convenience for the staff. An interview on 02/10/2022 at 9:30 AM with the Psychologist revealed facility staff did not contact him on 01/17/2021 about Resident #11 refusing to take their medication and staff administering a PRN [MEDICATION(S)] injection. He would not comment on the rational of another physician. The Psychologist stated that he believed that [CONDITION(S)] medication should be a last resort. The Psychologist also stated that his assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A telephone interview on 02/11/2022 at 1:00 PM with the resident's Physician revealed he was unable to answer questions related to Resident #11's change in diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician was unable to be interviewed following this telephone interview. A follow-up interview on 02/12/2022 at 10:07 AM with the ADON revealed that she agreed that residents with dementia needed a different type of care that should be individualized and sp

Based on observation, interview and record review, the facility failed to ensure 1 of 4 residents reviewed for falls received adequate supervision and assistance during a staff transfer to prevent accidents. (Resident #13) On 8/18/11, Certified Nurse Aide (CNA A) transferred Resident #13 without assistance of another staff member or hoyer lift resulting in a fall. Resident #13 was hospitalized for [REDACTED]. She returned to the facility on [DATE] with a splint on her left wrist and an immobilizer on her left leg. This deficient practice resulted in hospitalization for pain relief and splinting of the left wrist and an immobilizer to the left fractured femur for Resident #13 and placed an additional 13 residents identified as requiring two staff for transfers at risk of injury when staff failed to provide care and services specific to resident care plans. Findings include: Review of Resident #13's Face Sheet reflected admission to the facility on [DATE]. Resident #13 is a [AGE] year old female with [DIAGNOSES REDACTED]. Review of Resident #13's current Plan of Care in the CNA log at the nurse's stations revealed the following instructions for care: Transfer with assist of two (2) staff members. Observation on 8/24/11 at 10:20 AM at a local hospital (admitted for constipation on 8/21/11), revealed Resident #13 was resting in bed with a splint to her left wrist and an immobilizer to her left leg. During an interview at the time of the observation, Resident #13 stated she asked CNA A for assistance to the bedside commode on 8/18/11. CNA A got her on the bedside commode and realized she was wearing a brief. CNA A assisted her to her feet to remove the brief and Resident #13 lost her balance and she and the CNA fell to the floor. Resident #13 stated she was having pain in her wrist and leg. Review of a facility Investigation Report dated 8/18 /11 revealed the following: On 8/18/11 (no time), CNA A transferred Resident #13 by herself to the bedside commode. Resident #13 is a 2 person transfer. Resident 13 had a brief on and CNA A stood her up to remove the brief. Resident 13 stared to lean and the CNA lost her footing and both fell to the floor with Resident 13 being on top of CNA A. Abrasion to left shin, swelling and complaint of pain to the left wrist and left knee. Resident #13 was transferred to the hospital by ambulance. Review of the Final X-Ray Reports dated 8/18/11 revealed the following findings: Osteoporosis with acute supracondylar and intracondylar fracture distal femur above the prosthesis. none displaced fracture of the distal end of the radius and ulnar with prominent soft tissue edema and osteoporosis. During interview on 8/24/11 at 8:40 AM, the Director of Nurses (DON) stated that CNA A transferred Resident #13 alone. She stated the CNA's have a flow notebook at the nurses station with a flow sheet that explains the care needs of the residents. The flow sheet tells how to transfer and how many staff to use for transfers. Resident #13 required a two person transfer at the time of the incident. Random interviews on 8/22/11 through 8/24/11 with multiple CNA's from both day and evening shifts revealed they were all familiar with and used the CNA flow notebook for resident care information. During interview on 8/24/11 at 12:30 PM, CNA A stated, "The morning of 8/18/11 around 1:30 AM, Resident #13 stated she had an enema earlier and needed to get on the bedside commode. She was able to stand and help with the transfer. I got her on the commode and Resident #13 told me she had a brief on and when I assisted her to her feet to remove the brief, she lost her balance and we both fell . I did not know Resident #13 was a two (2) person transfer." Review of a staff in-service dated 1/17/11 revealed the following: Instructed CNA's on correct and safe transfer technique and proper use of gait belt. Review of the signatures of the staff attending the in-service reflected CNA A attended the in-service. Review of Resident #13's Plan Of Care date 2/2/10 and updated 6/2/11 reflected; Transfers: Assist two staff and hoyer lift. Review of the Documentation/Charting Record dated 6/1/11 through 6/30/11 reflected Resident # 13 required the assist of 2 CNA's for transfers and revealed CNA A's signature in the Nurses Signature area. During a telephone interview on 8/24/11 at 12:05 PM, Nurse Practioner (Resident #13's primary care provider) stated, "Resident #13 has no use of her left arm/hand and very little use of her left leg (due to a CVA (stroke) prior to the accident, and if the bones heal, her level of functioning would not change significantly." The Director of Nurses identified 14 residents who require a two person assist during transfers.