Every finding on record at Focused Care at Sherman

Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for four residents (Resident #36, Resident #35, Resident #15, Resident #21) in two rooms reviewed for environment The facility failed to ensure FAN #1 (located in Resident #35 and Resident #36's room) and FAN #2 (located in Resident #15 and Resident #21's room) provided by the facility were clean and properly maintained upon observations on 07/26/2026, 07/27/2026, and 07/28/2026. The failure placed residents at risk for unsanitary conditions and injuries resulting from environmental conditions.Findings included: Record review of Resident #36's Face Sheet dated 07/28/2026 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included myocardial infarction (compromised blood flow to heart causing tissue damage,) vascular disease (conditions that affect the circulatory system causing vessels to narrow or weaken,) malignant neoplasm of kidney (kidney cancer,) and anxiety (ongoing excessive fear, panic, or worry) and major depressive disorder (low mood, loss of interest in activity.) Record review of Resident #35's Face Sheet dated 07/28/2026 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included cerebral infarction (compromised blood flow to brain causing tissue damage,) vascular disease (conditions that affect the circulatory system causing vessels to narrow or weaken,) type 2 diabetes (insulin resistance,) and depressive disorder (low mood, loss of interest in activity.) Record review of Resident #21's Face Sheet dated 07/28/2026 revealed he was a [AGE] year-old male admitted to the facility 03/08/2023. Relevant diagnoses included cerebral infarction (compromised blood flow to brain causing tissue damage,) hemiplegia (paralysis) and hemiparesis (weakness) affecting right side, aphasia (brain disorder affecting how one speaks, understands, and writes,) and generalized anxiety disorder (excessive worry, physical tension occurring most days for 6 or more months.) Record review of Resident #15's Face Sheet dated 07/28/2026 revealed he was a [AGE] year-old male admitted to the facility 06/23/2023. Relevant diagnoses included chronic obstructive pulmonary disease (long-term lung disease affects the efficacy of oxygen exchange in the respiratory system,) dementia (decline in memory, language, problem solving,) and major depressive disorder (low mood, loss of interest in activity.) In observation and interview with Resident #36 on 07/26/2026 at 1:25 pm she was observed sitting in her room she shared with Resident #35. She was observed eating lunch. Fan #1 in the room was observed, turned on, functioning but with significant accumulation of dust, debris, and sediment. Resident #36 denied any respiratory distress at this time. She stated the condition of the fan did not bother her at this time. Resident #36 was not able to report when the last time any staff had cleaned the fan to her recollection. In observation and interview with Resident #35 on 07/27/2026 at 11:56 am the resident was observed in bed in his room. Resident #35 stated FAN #1 in his room was dirty and had been dirty for a while. FAN #1 observed in the room, turned on, and functioning but with significant accumulation of dust, debris, and sediment. Resident #35 denied any respiratory distress at this time but stated It would be nice if [the facility] would clean it. Resident #35 was not able to report the last time any staff had cleaned the fan to his recollection. In observation and interview with Resident #36 on 07/28/2026 at 3:38 pm, the resident was observed sitting in her room. Fan #1 in the room was observed, turned on, functioning; but with significant accumulation of dust, debris, and sediment. Resident #36 denied any respiratory distress at this time and denied any staff have attempted to clean the fan to her recollection. FAN #2, Resident #15 and Resident #21:In observation and interview of Resident #21 on 07/26/2026 at 11:12 am the resident was observed resting in his bed in his room. FAN #2 observed in the room, turned on, functioning but with significant accumulation of dust, debris, and sediment. Resident #21 denied any respiratory distress at this time by nodding his head left to right and demonstrated a thumbs up gesture when asked if the condition of the fan bothered him. Resident #21 demonstrated a thumbs up gesture when asked if he would like the fan to be cleaned. In observation and interview with Resident #15 on 07/26/2026 at 1:32 pm the resident was observed sitting in his room in his wheelchair. FAN #2 was observed in the room, turned on, functioning; but with significant accumulation of dust, debris, and sediment. Resident #15 denied any respiratory distress at this time. Resident #15 stated he was aware of the dirty fan in his room, stated it did not bother him at this time. In observation and interview with Resident #15 on 07/27/2026 at 11:44 am the resident was observed resting in bed. FAN #2 was observed in the room, turned on, functioning; but with significant accumulation of dust, debris, and sediment. Resident #15 was not sure when FAN #2 was cleaned last and denied any respiratory distress at this time. In observation and interview with the housekeeping staff assigned to the hall in question, Housekeeping W on 07/28/2026 at 2:08 pm, he observed both FAN #1 and FAN #2 in the residents' rooms and stated he did think they were dirty. He stated he did not recall how long they had been visibly dirty but stated he had not been instructed to clean the fans in any resident rooms. He stated a clean room was important for dignity, health, and wellness, but re-iterated he had not been instructed to clean the fans. In interview with the Housekeeping Supervisor on 07/28/2026 at 1:17 pm she stated it was the housekeeping responsibility to ensure resident rooms were kept clean with equipment like fans being properly cleaned and maintained. She stated she expected housekeeping staff to clean and properly maintain the fans inside the rooms. She stated now that the fans had been brought to her attention, she would add the fans to the deep clean schedule. She stated there was a fire risk if resident fans were not kept clean in addition to the allergen risk for the residents. She stated the residents had a right to a dignified existence and that was related to providing a clean, homelike environment. In interview with the DOCO on 07/28/2026 at 1:13 pm she stated that within the last month (the environment) has gotten bad. She stated the Housekeeping Supervisor had replaced some employees recently and she hoped things would improve. She stated she was not aware of any dirty resident fans. Stated the potential risk to the resident would be infection control and that she did not want residents to live in filth. She stated it would be the housekeeping department's responsibility to ensure resident rooms were clean. In interview with the facility's Administrator on 07/28/2026 at 3:43 pm she stated she expected the facility's environment to be clean. She stated it was housekeeping's responsibility to ensure resident environments were kept clean. She stated it was important to have the environment kept clean, otherwise it will feel germy and it won't feel like a homelike environment. Record review of the facility policy, Resident Rights, 12/2016 revealed: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. The rights include the resident's right to: a. a dignified existence, b. to be treated with respect, kindness, and dignity.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Residents #35 and Resident #27) of five residents observed reviewed for infection control. 1. LVN C failed to practice proper hand hygiene after completing her care with Resident #46 and prior to starting care with Resident #27 upon observation on 07/26/2026.2. LVN C failed to practice proper Enhanced Barrier Precautions and proper hand hygiene when providing care to Resident #27 upon observation on 07/26/2026.3. LVN C failed to practice proper hand hygiene after completing her care with Resident #27 and prior to starting care with Resident #35 upon observation on 07/26/2026. The failure placed residents at risk for infection and cross contamination.Findings included: Record review Resident #46's Face Sheet dated 07/28/2026 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included dementia (decline in memory, language, problem solving, and other thinking abilities,) type 2 diabetes (insulin resistance,) and seizures (abnormal burst of electrical activity in the brain that causes changes in movement, behavior, feelings, and/or awareness.) Record review of Resident #27's Face Sheet and Comprehensive Care Plan dated 07/28/2026 revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included acute respiratory failure (sudden inability for lungs to get enough oxygen into your blood,) dysarthria (motor speech disorder characterized by slurred or slow speech,) glaucoma (damage to the optic nerve causing gradual vision loss,) type 2 diabetes (insulin resistance,) acute kidney failure (sudden loss of kidney function that leads to a dangerous buildup of waste in blood,) and anxiety disorder (excessive ongoing fear and worry.) Resident #27 was on EBP for chronic wound or skin opening requiring dressing change/ESBL in urine. Intervention included Staff will maintain EBP while performing any time of device such as but not limited to the following: central line care, tracheostomy care, urinary catheter care, feeding tube care, and wound care with a start date of 02/12/2026. Record review of Resident #27's MDS dated [DATE] revealed she was admitted with unhealed pressure ulcers and was at risk for the development of more pressure ulcers. She required a wheelchair for mobility. Resident #27 was severely cognitively compromised with a BIMS score of 06. Record review of Resident #35's Face Sheet dated 07/28/2026 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included cerebral infarction (compromised blood flow to brain causing tissue damage,) vascular disease (conditions that affect the circulatory system causing vessels to narrow or weaken,) type 2 diabetes (insulin resistance,) and depressive disorder (low mood, loss of interest in activity.) 1 and 2:In observation and interview on 07/26/2026 at 11:21 am, revealed LVN C was in Resident #46's room, obtained blood sugar measurement and provided her with her ordered insulin. LVN C then removed her gloves, exited the room, and went to her designated medication cart. LVN C then began charting on a computer located on top of the medication cart. LVN C failed to perform hand hygiene after providing resident care and exiting the room. LVN C then stated she was going to Resident #27's room, that [Resident #27] was on EBP for ESBL and obtained a gown and gloves. LVN C then donned (applied/put on) the gown and gloves prior to entering Resident #27's room. LVN C then disconnected Resident #27's IV medication tubing by touching the port with her right gloved hand and the IV medication tubing with her left gloved hand. LVN C then removed her gloves and gown and returned to her medication cart. LVN C failed to perform hand hygiene prior to donning PPE, entering Resident #27's room, and making contact with Resident #27's IV. LVN C also failed to perform hand hygiene after removing her gloves and exiting Resident #27's room. LVN C was observed documenting on the computer located on top of her designated medication cart. Then, LVN C went back into Resident #27's room and stated it was to obtain her blood sugar. LVN C donned gloves but failed to perform hand hygiene prior to donning gloves and failed to don a gown. Once LVN C obtained Resident #27's blood sugar, she returned to her designated medication cart, sanitized the blood sugar monitor and removed her gloves. LVN C then obtained a new set of gloves and entered Resident #27's room again. LVN C failed to don a gown or perform hand hygiene prior to donning gloves and providing resident care. LVN C donned gloves and sanitized Resident #27's IV port hub and then flushes Resident 27's IV with approximately 10 ccs of normal saline. LVN C then removed her gloves, and returned to her medication cart outside of the resident's room. 3.In observation immediately following the previous observation on 07/26/2026 at 11:48 am, revealed LVN C provided medication to Resident #35 in the hallway with the resident's consent, immediately after she returned to her medication cart after flushing Resident #27's IV. LVN C failed to perform hand hygiene after she removed her gloves after exiting from Resident #27's room, failed to perform hand hygiene prior to obtaining Resident #35's medication. No hand hygiene was observed during the observation with Resident #35 at this time. In interview with LVN C on 07/26/2026 at 11:55 am she stated she was nervous and knew she should perform hand hygiene prior and after donning gloves. She stated she knew she was required to don PPE in Resident #27's room because she was on EBP precautions for ESBL. She stated it was important to adhere to infection control polices and procedures to prevent the spread of infection. She stated it was her responsibility and stated she felt like she had been adequately trained, she was just nervous at the time of observation. In interview with the facility DOCO on 07/26/2026 at 12:13 pm she stated it was her expectations for all staff to adhere to infection control policies and procedures. She stated that LVN C should have performed hand hygiene before and after glove changes and between resident contact and care. She stated she expected LVN C to gown up again when she re-entered a resident's room with EBP precautions per facility policy, protocol, and procedure. In a follow up interview with the facility DOCO on 07/26/2026 at 12:35 pm, she stated she did not expect LVN C to don a gown to obtain blood sugars but she did expect her to wear PPE (gown and gloves) when Resident #27's IV was flushed. She stated it was important for her staff to adhere to infection control policies and procedures to prevent the spread of infection. In interview with the facility's Administrator on 07/28/2026 at 3:43 pm, she stated she expected all staff to adhere to infection control policies, protocols, and procedures. She stated it was the DOCO's responsibility to ensure her staff were trained and competent in infection control. She stated it was important for infection control purposes and the safety of her residents. Record review of the CDC's guidance, Frequently Asked Questions about Enhanced Barrier Precautions in Nursing Homes, 06/28/2024, revealed: 1. What are Enhanced Barrier Precautions? Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). 2. What are the differences between Enhanced Barrier Precautions and Standard Precautions? . Enhanced Barrier Precautions expand the use of gown and gloves beyond anticipated blood and body fluid exposures [i.e. blood exposure via blood sugar assessment.] They focus on use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Standard Precautions still apply while using Enhanced Barrier Precautions. For example, if splashes and sprays are anticipated during the high-contact care activity, face protection should be used in addition to the gown and gloves. < https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html> Record review of the facility policy, Handwashing/Hand Hygiene rev. 08/2015, revealed 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 6. Wash hands with soap and water. a. when hands are visibly soiled and b. after contact with resident with infectious diarrhea. 7. Use an alcohol-based hand rub. or soap and water for the following situations: b. before and after direct contact with residents, c. before preparing or handling medications, d. before performing and non-surgical invasive procedures, e. before and after handling an invasive device. h. before moving from a contaminated body site to a clean body site during resident care, i. after contact with a resident's intact skin. l. after contact with objects in the immediate vicinity of the resident, m. after removing gloves. Record review of facility policy Infection Control, dated 04/01/2024, revealed Policy. Enhanced Barrier Precautions (EBP) are a CDC guidance to reduce the transmission of Multi-Drug resistant organisms (MDRO) in health care settings. EBP require team members to wear a gown and gloves while performing high-contact care activities with residents. High contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any skin opening or requiring a dressing.

Based on interviews and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies for 1 of 1 facility reviewed for facility assessment. The facility failed to ensure the daily staffing needs were followed according to the facility assessment. This failure could place residents at risk of inadequate care or treatment and a decreased quality of life. Findings included: During a confidential group meeting on 07/27/2026 at 2:05 PM, the group reported when it came to residents' needs the CNAs repeatedly told them they were short staffed so if some things did not get done in a timely manner or were taking too long to assist them that was the reason why they were taking so long. The group reported it made them feel like they should not request assistance from the CNAs. During an interview on 07/28/2026 at 1:48 PM Resident # 44, when asked if a lot of staff came to help he, she stated that there was not a lot of staff that worked on the floor. Resident #44 stated only 1 CNA most of time. Resident #44 stated it as really hard to get help at night, and that she only saw one CNA working at night and was unsure who the nurse was. Resident #44 stated the nurse did not check on her at night. When asked if she felt t safe at the facility, Resident #44 stated Sorta. Resident #44 added that she was not getting the help that she needed. She stated that when she called on someone at night, they got mad. During an interview on 07/28/2026 at 1:58 PM Resident #10 stated they felt safe at the facility. Resident #10 stated that at night staffing was bad, he stated it took a long time for staff to assist other residents. Resident #10 stated that he as usually sitting in the hallway until 2 am or 3 am. Resident #10 stated there were usually only 2 aides in the whole facility, and one was working the main halls and the other staff was in the locked unit across the hall. Resident #10 stated he was concerned there was not enough staff to meet other residents' needs. During an interview on 07/28/2026 at 2:00 PM Resident #55 stated it took a long time for staff to help at night. Resident #55 stated that on the weekends it's difficult and they are short staffed not here. He stated that he has to get up and go to the nursing station to get what he needs. Resident #55 stated he does not have concern for his care and he can care for himself; and It's the other residents he has a concern for due to staffing issues. Resident #55 stated they are always short staffed with both nurses, CNAs . and it takes a long time to get help. During an interview on 07/28/2026 at 11:00 AM ASM A stated sometimes they were short, and they tried to call in other staff members, they notified the ADON and DON, and if it was the weekend they notified the weekend RN. ASM A said sometimes they were told to do the best they could. ASM A stated on if they did not have enough staff, it could affect the residents because they would not receive proper/timely care. During an interview on 07/28/2026 at 3:10 PM ASM B stated pertaining to the staffing of CNAs, it was her responsibility for the hiring of CNAs. ASM B stated, It has been an ongoing issue for the concerns that have been brought up from both residents and other staff, they have expressed a concern about staffing. ASM B stated it is in part to due to the census that drives the budget. ASM stated they do not use temporary/contract staff, the practice was stopped July 14th of 2025. ASM B stated there is not enough adequate coverage at the CNA staffing position when it comes to providing care. ASM B stated there is a great risk to residents that do not have enough staff coverage from CNAs, LVNs to RNs. ASM B stated management was aware they have been having to work short. ASM B stated not having enough staff to provide care to the residents could affect their care because they would not get toileted on time or they would have to wait long periods of times to be changed, and that could result in an increased risk for skin breakdown. ASM B stated there were four CNAs , and one med aide from 6-2 and med aide from 2-10 and 2 nurses. ASM B stated the negative effect on residents would be that residents are not treated with dignity and respect. ASM B stated it has been brought to the attention of the staff for the issues. ASM B stated I do not feel the residents get the quality of care that they deserve. Record review of the Facility assessment dated [DATE] indicated, staffing Plan2. Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time. Staff (Licensed Nurses (LN):RN,LPN,LVN providing direct careDOCO:RN full time days; ADOCO:LVN full time days Charge Nurses: 2 6a/6p & 2 6p/6aMDS:1 Treatment Nurse 1Medication Aides weekdays. Nurse Aides - Certified Nurses 5 on 6a/6p & 4 on 6p/6a Record review of time sheets dated 07/07/2026 indicated only 2 CNAs worked the 12 hour second (6:00pm - 6am) shift Record review of time sheets dated 07/07/2026 indicated 1 CMA worked the entire 8 hour first (6:00 a.m. - 2:00 p.m.) shift. Record review of the facility's policy, Staffing, Sufficient and Competent Nursing, undated, indicated, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. 1.Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. 2. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. 3. Other support services (e.g., dietary, activities/recreational, social, therapy, environmental, etc.) are also staffed to ensure that resident needs are met.

Based on observation, interviews, and record reviews, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure all food items in the kitchen were dated and discarded by their use-by date and were properly sealed. The facility failed to ensure the tea was properly covered with a lid.This failure could place residents at risk for food contamination and food-borne illness.Findings Included: An observation on 07/26/2026 between 9:10 AM and 9:35 AM in the facility's kitchen revealed. One gallon bag containing tortillas open date of 07/20 with no visible expiration date. One 10lbs. bag containing pasta elbow noodles dated 06/28 with no visible expiration date. One 10lbs. bag containing spaghetti noodles dated 07/15 with no visible expiration date, not properly sealed and exposed to air. Tea dispenser in the kitchen area, covered with a serving tray and exposed to air-borne contaminants.One 10lbs. bag containing penne noodles open date of 07/15 with no visible expiration date. One box containing red bell peppers, with brownish mold. One 5lbs. bag containing shredded cabbage with a use by date of 07/16/26. One gallon bag containing cheese dated 06/25 with no visible expiration date. One gallon bag containing yogurt dated 07/19 with a use by date of 07/22. One 5lbs. plastic tub containing sour cream with use by date of 07/21/2026. One 18.66lbs. bag of ham with an open date of 07/23 with no visible expiration date. One 25lbs. box containing green peppers bruised and covered with a brownish stain on them. One plastic wrapped bag containing chicken parts dated 07/19 with a use by date of 07/23, not properly sealed and exposed to air. One gallon bag of chicken strips with an open of date 07/26 with no visible expiration date. One gallon bag containing fish with an open date 06/19, with no visible expiration date. One gallon bag containing Mc ribs with an open date of 07/08/26 with no visible expiration date. One gallon of iced tea dated 07/25/26 with a use by date of 07/27/26, not properly sealed and exposed to air. One 20lbs. opened box of broccoli [BR68.1][DW68.2]with a brownish substance on broccoli florets. One plastic bag containing frozen chocolate cookies, with no visible dates, not properly sealed and exposed to air contaminants. During an interview on 07/26/26, at 10:14 AM, FSA B stated on today's date she was responsible to ensure the tea dispensers were covered. She stated preparing the tea and not covering the tea dispenser may cause cross contamination and could lead to sickness among residents. The tea dispenser was supposed to be covered with a lid after the brewing process, and not a tray. FSA B stated items should be labeled, with a brew date and time, followed by a discard time. and the risk of the concerns not being addressed could result in food-borne illnesses. [NAME] B stated the risk of serving foods that were past the use-by date, or serving food that was not labeled or dated, could cause food borne illness to residents. During an interview on 07/28/2026 at 11:45 AM the DFS stated she was the person responsible for ensuring the kitchen was meeting guidelines for food storage and kitchen sanitization. The DFS stated once items were opened, they should be properly sealed and dated. The DFS stated she was responsible for ensuring policy was followed. The DFS the kitchen staff were responsible for labeling and making sure that the items were labeled properly. The DFS stated the risk to residents if policy was not followed was a health risk to the residents. The DFS stated the items should be labeled, and the risk of the concerns not being addressed could result in food-borne illnesses. The DFS stated the risk of serving foods that were past the use-by date, or serving food that was not labeled or dated could cause food borne illness to residents. During an interview on 07/28/26, at 1:55 PM, the EDO stated oversaw all departments, and ensured residents were taken care of. The EDO stated the issues could cause food contamination. If items were expired, they should not serve them to residents. The EDO stated her expectation was for the DFS and kitchen staff to ensure that the kitchen staff followed all guidelines, including ensuring the food items were labeled properly in the kitchen. Record review of Facility's policy on Food Safety, Food Storage revised dated 04/2026, revealedPOLICY Food should be stored in a safe and sanitary method to prevent contamination and food-borne illness. All food should be stored according to local, state and federal regulations. 1. Dry storage rooms b. Food items should be dated with received date. This may sometimes be noted on the food vendor label on the package. c. Food items removed from their original packaging should be labeled and dated. 2. Refrigerators c. Refrigerated food should be dated, labeled and sealed. d. Leftovers should be used within 3 days. Discard items after 3 days. 3. Freezers d. Items should be sealed, labeled and dated. Review of TITLE 21--FOOD AND DRUGS CHAPTER I--FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICESSUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION PART 110 -- CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKING, OR HOLDING HUMAN FOOD Texas Chapter 228 Retail Food adopts the U.S FDA Food Code. 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. Commercially processed food Open and hold cold (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. Pf (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest prepared or first-prepare.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assured accurate administering of all drugs to meet the needs of the residents, for one (Resident #28) of five residents reviewed for medication administration. The facility failed to ensure RCP B provided her prescribed dose of Alprazolam to Resident #28 on 07/25/2026 around 8:00 pm. The failure resulted in Resident #28 receiving the incorrect dose of her medication.Findings: Record review of Resident #28's Face Sheet dated 07/28/2026 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included nontraumatic subdural hemorrhage (blood accumulation around the brain causing a dangerous pressure level), bipolar disorder (mental health condition defined by extreme shifts in mood), anxiety disorder (mental health condition defined by excessive, ongoing fear or worry), seizures (sudden surges of abnormal electrical brain activity.) Record review of Resident #28's Quarterly MDS Assessment, dated 06/03/2026 revealed she had severe cognitive impairment with a BIMS score of 05. She exhibited no signs or symptoms of delirium, hallucinations, and/or delusions. She was continent of bowel and bladder. Resident #28 required partial/moderate assistance with hygiene, toileting, and dressing herself. Record review of Resident #28's Provider Orders on 07/28/2026 revealed:Alprazolam Oral Tablet 1 mg . Give 1 tablet by mouth three times a day May give two 0.5 mg tablets to equal 1 mg . with a start date of 02/16/2025.Alprazolam Oral Tablet 1 mg . Give 1 tablet by mouth three times a day for anti-anxiety . with a start state of 02/26/2025.Alprazolam Oral Tablet 0.5 mg . Give 1 tablet by mouth three times a day for anxiety . with a start date of 06/18/2026.Alprazolam Oral Tablet 0.5 mg . Give 1 tablet by mouth two times a day for anxiety . with a start date of 07/26/2026. In observation of Resident #28's physical Medication Packet used on 07/25/2026 on 07/28/2026 at 1:11 pm revealed [Resident #28]. Alprazolam 1 mg. give one tablet by mouth three times daily. dated 07/24/2026. Record review of facility's initial incident report dated 07/27/2026 revealed: Brief narrative summary of the reportable incident: During the 6:00 am medication pass, the night nurse discovered that the [Resident #28's] [Alprazolam] available for administration was 1 mg rather than the 0.5 mg dose ordered by the physician. The physician had previously changed the order to [Alprazolam] 0.5 mg by mouth twice daily, for a total daily dose of 1 mg. Upon review, it was determined that the resident had inadvertently received two 1 mg tablets instead of the prescribed 0.5 mg dose (the previous night.) Record review of Resident #28's vital signs documented in her EMR immediately after the incident was determined, revealed data on 07/26/2026 documented to be within normal limits:5:57 am 104/51 mmhg, 56 bpm7:04 am 110/64 mmhg, 65 bpm8:03 am 104/56 mmhg, 65 bpm8:57 am 126/58 mmhg, 73 bpm10:03 am 114/54 mmhg, 62 bpm10:58 am 128/69 mmhg, 69 bpm11:58 am 123/65 mmhg, 58 bpm1:02 pm 128/64 mmhg, 69 bpm2:03 pm 143/64 mmhg, 72 bpm7:18 pm 124/72 mmhg, 69 bpm Record review of Resident #28's Comprehensive Care Plan dated 06/24/2026 revealed:-Resident is on sedative/hypnotic therapy related to insomnia . dated 01/11/2024.-Resident uses anti-anxiety medications related to adjustment issues, anxiety disorder . dated 01/11/2024.-Impaired cognitive function or impaired thought process related to cognitive loss and impaired decision-making abilities, not always understood or able to understand verbal and non-verbal expression . dated 01/11/2024.-Moderate risk for increased falls and fractures as evidence of prior falls prior to admission . dated 01/11/2024.-Potential to be physically aggressive related to anger, dementia, depression, poor impulse control . dated 01/11/2024.-Potential to be verbally aggressive related to dementia, ineffective coping skills, mental and emotional illness, poor impulse control . dated 01/11/2024.-Resident on the facility secured unit due to wander/elopement risks related to impaired safety awareness . dated 01/11/2024. In observation and interview with Resident #28 on 07/28/2026 at 8:39 am, she was observed resting in bed. She was clean, dressed, and displayed no signs of distress or over sedation. Resident #28 reported she did not recall the incident but was aware she took medications to help her sleep. She denied being over sedated or the inability to stay awake during the daytime hours. In interview with Resident #28's medication aide for the day MA Z on 07/28/2026 at 9:17 am, she stated the resident was provided with her medications this morning and did not seem over-sedated or over-medicated. She stated her baseline fluctuated with her clinical conditions, but she was at her baseline as far as she could tell. She stated she was aware of the incident, stated it was her responsibility to provide medications safely, and reported sufficient training in the rights of medication administration. In interview with RCP B who also performs medication aide duties at the facility on 07/28/2026 at 8:53 am revealed she worked the night of the incident and provided Resident #28 with her medications that evening. She stated as she gathered Resident #28's medications, she did not recall what the dose on the medication sleeve stated, but she provided two pills of [Alprazolam.] RCP B stated she should have double checked the medication sleeve and she owns it. She stated it was her responsibility to ensure the medication she provided was per provider orders and if she failed to do this, it was a safety concern. In interview with facility's DOCO on 07/28/2026 at 10:44 am and 11:42 am she stated she was informed of the incident early Sunday morning, 07/26/2026. She stated she promptly went to the unit to investigate and assess Resident #28. Facility DOCO stated she was able to identify that the resident received 2 mg of her Alprazolam instead of her prescribed 1 mg. She stated when she assessed the resident she reported a great night's sleep, and from what she could assess, she was at her cognitive baseline. She stated Resident #28's responsible party and provider was notified, and in response her morning dose of Alprazolam was held and she was closely monitored for 8 hours during the day. DOCO stated Resident #28 had no observable harm or adverse effects. She stated she completed an investigation and Resident #28's provider reduced her medication previously, but the resident had complained about having a hard time sleeping. Facility DOCO stated the provider had re-ordered a 1 mg dose at bedtime while continuing her 0.5 mg dose during the daytime. She stated it was the responsibility of RCP B and any other staff providing medications to residents to adhere to the facility policy related to administering medications for resident safety. In interview with facility's Administrator on 07/28/2026 at 3:43 pm she stated she was aware of the incident and that RCP B promptly took accountability, but she should have doubled checked. She stated the resident did not experience any harm, but it was important for her staff to provide medications as provider ordered, otherwise there was a risk of them having acute distress. Record review of facility In-service & Education Record, titled Controlled Substances, dated 07/26/2026 conducted by facility DON detailed regulations and laws related to the handling, storage, disposal and documentation on controlled substances . with multiple LVN and MA signatures, including RCP B. Record review of facility policy Administering Medications, rev. 04/2019, revealed:2. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions . 4. Medications are administered in accordance with prescriber orders, including the required time frame.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical well-being for 1 (Resident #55) of 6 residents reviewed for care plans. The facility failed to ensure that Resident #55's care plan included the use of a wheelchair for mobility. This deficient practice could place the resident's mobility needs and required assistive equipment at risk of not being accurately assessed, communicated, or addressed.The findings included:Record review of Resident #55's admission Record revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Hypertension (the force of blood pushing against your artery walls is too high) onset date of 09/29/2025, Diabetes Type 2 (chronic medical condition where the body becomes resistant to insulin, does not make enough, causing sugar to build up in the blood) onset date of 09/29/2025, Hyperlipemia (excess of fats in the blood) onset date of 09/29/2025, Cerebral Infarction ( blocked blood vessel stops blood and oxygen from reaching an area of the brain, causing brain tissue to die) onset date of 09/29/2025.Record review of Resident #55's most recent admission MDS assessment dated [DATE] revealed that Resident #55 uses a walker for mobilityRecord Review of Resident #55's most recent quarterly MDS assessment dated [DATE] revealed that Resident #55 uses a walker for mobility.Record review of Resident #55's comprehensive care plan, dated 02/05/2026, did not reveal anything related to mobility devices used.During an interview on 07/26/2026 at 11:31 am, Resident #55 revealed that the wheelchair was given by the Rehabilitation Department at the facility. Resident #55 revealed that the wheelchair was given due to his recent falls.Observation on 07/26/2026 at 11:40 am revealed that Resident #55 transferred himself from the bed to his wheelchair and exited the room.Interview on 07/26/26 at 11:55 am with the Director of Rehabilitation revealed that Resident #55 had a walker when he was first admitted . He revealed that it was recommended that Resident #55 have a wheelchair as well as a choice for the resident. He stated that the care plan is updated collaboratively. He revealed that the risk to the residents of not providing a revised care plan could cause a delay in accurate services rendered for the residents.Interview on 07/27/2026 at 12:52 pm with the CRC revealed it is an IDT effort to ensure that the Comprehensive Care Plan was updated. CRC revealed that not updating the care plan could place the residents at risk of interruption of care due to inaccurate information.Interview on 7/26/26 at 2:31 PM DOCO revealed that if a resident used a wheelchair, this information would be located within the care plan. DOCO revealed that the IDT is responsible for ensuring that the comprehensive care plans are updated. DOCO revealed that the care plan should reflect each device the residents are using for accurate care and proper intervention planning. DOCO revealed that not having mobility devices care-planned poses a risk to safety, education, and planning.Record review of the facility policy titled Resident Assessment with an effective date of 01/20/2021 and a revision date of 04/25/2021 revealed in part, The Care Plan is revised every quarter, significant change of condition, annually, or as the resident condition changes on an individualized basis.

Based on interview and record reviews, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of all the facility's resident population in accordance with the facility dietary staff. The facility failed to ensure there were sufficient kitchen staff to timely carry out the functions of lunch services on 07/17/26. This failure could place residents who consumed food prepared from the kitchen at-risk of foodborne illness or nutritional deficiencies. Findings included: During an interview on 07/23/26 at 2:17 PM, the Director of Food & Nutrition Services stated on 07/17/26 she was out sick. She stated she received calls from Food Service Manager E and Food Service Assistant F that they were not getting along. The Director of Food & Nutrition Services stated the Food Service Assistant F clocked out and left in the middle of serving lunch. She stated on 07/17/26, Food Service Assistant F walked out of the building and quit. The Director of Food and Nutrition Services stated she had to call her evening staff to come in early that day to serve lunch. She stated on 07/17/26 the residents were served lunch around 2:00 PM. She stated the residents were served ham and cheese sandwiches. She stated the effect of the staff quitting was not having proper staff and caused the lunch to be late. During an interview on 07/23/26 at 2:23 PM, the Food Service Manager C stated on 07/17/26 he and Food Services Assistant D were called into work early by the Director of Food & Nutrition Services. He stated he was not at work during the time that Food Service Assistant F walked out, but he heard about it. He stated when he and Food Service Assistant D went into work early, they prepared lunch because it had not been done by the morning shift. He stated they made the residents peanut butter and jelly sandwiches and ham and cheese sandwiches. Food Service Manager C stated residents received their lunch around 2:00-2:30 PM. He stated lunch was supposed to be served at 12:00PM. He stated the effect of staff walking out was that the residents were served a different meal and it was late being served. During an interview on 07/23/26 at 2:28 PM, Food Service Assistant D stated on 07/17/26 another aide walked out during lunch. He stated he and the Food Service Manager C received a call to go into worker early to assist with lunch. He stated he did not know exactly what had transpired with the staff that walked out. He stated the aide that walked out left the dish area a mess. Food Service Assistant C stated the residents were served ham and cheese and peanut butter sandwiches. He stated that day they were late serving lunch. He stated residents received their lunch around 2:30 PM. An attempted call on 07/23/26 at 2:39 PM was made to interview Food Service Assistant F but received a message from the operator that stated, the person was not able to receive calls and unable to leave a message. An attempted call on 07/23/26 at 2:41 PM was made to interview Food Service Manager E but there was no answer. Record review of daily dining schedule on 07/23/26 at 3:44 PM, reflected the following: Breakfast 7:00 AM Lunch 12:00 PM Dinner 5:00 PM Record review of facility's lunch menu for 07/17/26 reflected the following: Lunch on 07/17/26 consisted of: popcorn shrimp, macaroni & cheese, fried okra, roll, chocolate yogurt mousse, iced tea and water. Record review of grievances, dated 07/20/26, reflected residents in general comprised of food service. Record review of Food Service Assistant F's statement to HR on 07/21/26, reflected the following: [Food Service Assistant F] was writing to formally report serious concerns regarding previous work environment. First, [Food Service Assistant F], report instances of personal harassment and bullying. [The] behavior was unacceptable, and [wanted] to discuss the steps that would be taken to address the situation and ensure a safe and respectful environment. A policy regarding dietary staffing was requested on 07/23/26. Record review of the policy, tilted Sufficient Staffing, revealed the following: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. 2. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. 3. Other support services (e.g., dietary, activities/recreational, social, therapy, environmental, etc.) are also staffed to ensure that resident needs are met.

Based on observations and interviews the facility failed to ensure reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for the bedrooms of 1 of (Resident #1) 5 resident rooms reviewed for resident call systems. The facility failed to ensure the call lights in the rooms were within reach for Resident #1, making it inaccessible if the resident needed assistance. This failure could place residents at risk of being unable to have a means of directly contacting caregivers.Findings included:Record review of Resident #1's face sheet, dated 07/23/26, reflected an [AGE] year-old female that was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: urinary tract infection, anuria (a medical emergency defined as the absence of urine production or passing less than 100 milliliters of urine per day) and oliguria (low urine output), hypoglycemia (low blood sugar), metabolic encephalopathy (a brain function disorder caused by systemic illness, organ failure, or chemical imbalances), chronic obstructive pulmonary disease (a long-term lung condition causing blocked airflow and breathing problems), gout due to renal impairment (when kidneys don't function optimally, they fail to filter uric acid effectively, leading to dangerous build-up in the blood), acute metabolic acidosis (a serious medical condition where too much acid builds up in the body or too much base (bicarbonate) is lost, causing a sudden drop in blood pH below 7.35), dysphagia (trouble swallowing), myocardial infarction (when blood flow to the heart muscle is blocked, causing tissue damage or death), lack of coordination (a loss of full control of bodily movements that commonly affects walking, balance, and fine motor skills), dysarthria (a motor speech disorder characterized by slurred, slow, or difficult-to-understand speech) and anarthria (a severe medical condition involving the complete loss of the ability to articulate or produce spoken words), extended spectrum beta lactamase resistance (enzymes produced by bacteria that break down and destroy common antibiotics), acute pyelonephritis (a sudden, serious bacterial infection of the kidney), hypomagnesemia (an electrolyte disorder featuring low blood magnesium levels), disorder of kidney and ureter (kidney stones, ureteral obstructions, and infections), altered mental status (a sudden or progressive change in a person's thinking, awareness, attention, or level of consciousness), need for assistance with personal care, hypotension (low blood pressure), atrial fibrillation (a common heart problem where the upper chambers of the heart beat fast and out of rhythm), hyperkalemia (high blood potassium levels), muscle weakness, unsteadiness on feet, cognitive communication deficit (a breakdown in communication caused by impaired mental processes like attention, memory, and executive function rather than a pure loss of speech or language mechanics), hypertension (when the force of blood pushing against your artery walls is consistently too high), abnormalities of gait and mobility (a change in how a person walks or moves, such as limping, shuffling, or losing balance), bell's palsy (a sudden, temporary condition that causes weakness or paralysis on one side of the face, drooping of the mouth, and trouble closing the eye), acute pancreatitis without necrosis or infection (inflammation and swelling of the pancreas), arthritis (a general term for conditions that cause joint pain, swelling, and stiffness), spinal stenosis (the narrowing of the spaces within the spine), acute kidney failure (a sudden, rapid loss of kidney function that happens over hours or days), shortness of breath, type 2 diabetes (a chronic condition where blood sugar levels are too high because the body does not make enough insulin or cannot use it properly). Record review of Resident #1's Quarterly MDS assessment, dated 05/21/26, reflected a BIMS score of 05, which indicated severe cognition impairment. The MDS assessment under Section GG-Functional Abilities, reflected Resident #1 was dependent with toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, supervision with oral hygiene and substantial assistance with showering/bathing self. Record review of Resident #1's care plan, revised 10/07/25, reflected Resident #1 required two staff members present for ADL care at all times. It further reflected that Resident #1 was at risk for increased falls and fractures as evidenced by history of falls and unsteady gait. The interventions included: ensuring call light was in reach and answered promptly. Resident #1's care plan also reflected that Resident #1 complained of increased pain, discomfort and was at risk for injury from decreased ADLs with arthritis. Intervention included: the resident being able to call for assistance. During an interview and observation on 07/23/26 at 10:35 AM, Resident #1 was observed lying upright in her bed. Resident #1's call light was observed tangled around her bed rail with the call button facing the floor. Resident #1 attempted several times to reach her call light with her left hand but was unable as it was tangled and not within reach. Resident #1 expressed that she was unable to grab her call light with her left hand. Resident #1 stated she could not use her right hand to grab it. During an interview and observation with LVN A and CNA B on 07/23/26 at 10:47 AM, LVN A and CNA B revealed that the call light for Resident #1 was not within reach. CNA B stated she did not know what happened to Resident #1's call light but she had attached it to the bed. LVN A stated the risk to residents were that they were unable to call for help. CNA B stated the risk to the resident when the call light was not within reach was that anything could happen and they would not be able to call for help. Both LVN A and CNA B stated it was there responsible to ensure the call light was within reach of the residents. A policy regarding call lights was requested but a Bedroom policy was received. The policy did not address call lights.

Based on observation, interviews and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents and/or hazards as possible for 1 of 6 residents (Resident #1) reviewed for supervision and accident hazards. The facility failed to ensure Resident #1 had adequate supervision when she failed to return inside the building following a smoke break on [DATE] at approximately 7:00 p.m. The facility failed to realize Resident #1 was not in the building until approximately 8:30 p.m. Resident #1 was found by the police on [DATE] at 8:47 p.m. deceased . The Resident was found less than 1/2 mile from the facility down a 20 - 30-foot creek embankment, tangled in tree roots and vines. An IJ was identified on [DATE]. The facility was notified and was given the IJ template on [DATE] at 2:51 p.m. While the IJ was removed on [DATE] at 5:15 p.m., the facility remained out of compliance at a scope of isolated and a severity level of not actual harm with potential for more than minimal harm that was not immediate jeopardy because the facility needed to evaluate the effectiveness of its corrective systems. These failures could place residents at risk of experiencing accidents, injuries, and/or death. Record review of Resident #1's face sheet, dated [DATE], revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: Type 2 Diabetes Mellitus (insulin resistance and a relative lack of insulin; causes high blood sugar levels), Hypertension (a condition in which the force of the blood against the artery walls is too high), Hemiplegia and Hemiparesis (partial weakness on one side of the body) following cerebral infarction (Stroke) affecting right dominant side, Depression, Acute Kidney Failure (a condition in which the kidneys suddenly cannot filter waste from the blood), and Intracranial space-occupying lesion found on diagnostic imaging of the central nervous system (tumor in brain).Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 13 which meant cognitive function was intact. The MDS revealed she had moderate hearing difficulty, there was no acute change in mental status, and she was not feeling down or depressed. Resident #1's MDS revealed she needed supervision/touch assistance for eating, oral hygiene, toilet hygiene, upper and lower dressing, putting on footwear and personal hygiene. Resident #1 needed partial assist for showering, and she did not have any assistive mobility aids.Record review of Resident #1's care plan, dated [DATE] revealed she was followed by psychiatric services for routine monitoring and support. Resident #1 had a diagnosis of Depression and was at risk for self-care deficit, ineffective coping, deficient diversional activity, and insomnia. Resident #1 had a history of trauma related to sexual and physical abuse which may impact emotional well-being, trust, and sense of safety.Record Review of Resident #1's Elopement Assessment dated [DATE] revealed her risk to be medium risk due to cognitive impairment, visual impairment, independent in ambulation, and verbally expressed desire to go home.Record review of Resident #1's progress notes revealed:On [DATE] at 2:10 p.m., the LVN documented resident (#1) was seen scurrying from her room to the empty room across the hall. This nurse then went to investigate, and resident was found the resident with some of her belongings and looking outside the window. When asked, resident said she was just looking and didn't want to wake her roommate. Redirected resident and her belongings back to her room. Will continue to monitor.On [DATE] at 11:45 p.m., the LVN documented Resident (#1) was found at the back door in dining room attempting to put in the code to go out the back door. She was redirected back to her room.On [DATE] at 9:00 a.m. the DCO documented spoke with resident (#1) and educated resident on smoking policy regarding signing out for smoking when outside of smoke break schedule. Resident voiced understanding and agreed to the rules.On [DATE] at 9:15 p.m., the LVN documented was notified by CNA that she was unable to locate resident. This nurse immediately asked staff and assisted with checking all the rooms. This nurse called DCO, did not get an answer. This nurse then called the on call and notified on call that the resident was nowhere around. DCO then returned call, notified DCO of elopement. The DCO stated to call 911 and continue checking rooms. Notified other nurse to call 911 and report resident missing. Staff went to check outside. This nurse then drove around the area looking for the resident (#1). This nurse checked at.gas station, drove around the cemetery, then up and down.(the street). This nurse received a call from the EDO regarding the elopement as well. This nurse notified EDO that she was out looking for the resident. This nurse arrived back at the facility where she was met by police. Assisted police with information as requested.On [DATE] at 9:28 p.m., the DCO documented Notified by charge nurse at this time that resident was actively missing from the facility and Code Pink had already been initiated for search of the facility, exterior of the facility and by car a parameter of 2 miles. When resident (#1) was unable to be located this nurse address to call 911, while I contact all parties. Attempted to contact resident on cell phone 24 times without answer. Notified (RP) only contact listed on and own (RP), MD stated notify me when you find resident. Notification made to RDCO of details at this time. Provided all available information to detective in lead of the case at this time. Continue investigation and search at this time.On [DATE] at 5:15 a.m., the LVN documented Called.(local hospitals) to see if this nurse could locate resident (#1). Both hospitals deny having a patient by her name.On [DATE] at 9:55 a.m., the ADON documented This nurse has attempted to call resident 27 times on her personal phone with no success in getting resident to answer. Multiple voicemails have been left for a return call. Will continue calling resident as long as phone is on and ringing.On [DATE] at 9:53 p.m., the LVN documented This nurse called to inform the resident's care conference person RP of the resident's passing. RP stated if we need anything else from him to call.Record review of Resident #2's face sheet, dated [DATE], revealed an [AGE] year-old female who was admitted on [DATE]. Diagnoses included: COPD (a group of lung diseases that blow airflow and make it difficult to breath), Dementia (loss of memory, language, problem solving and other thinking abilities that interfere with daily life), and anxiety.Record review of her Quarterly MDS, dated [DATE] revealed a BIMS score of 09 which meant moderate cognitive impairment.Record review of Resident #2's care plan dated [DATE] revealed she was a fall risk due to unsteady gait and generalized weakness. Resident #2's care plan revealed she had impaired cognition and memory loss due to dementia.Record review of Resident #2's assessments revealed an Elopement Assessment was updated on [DATE] as stated she did not have exit seeking behaviors.Record review of Resident #4's face sheet, dated [DATE], revealed she was a [AGE] year-old female, who was admitted on [DATE]. Her diagnoses included: Type 2 Diabetes, Vascular Dementia (occurs when blood flow to brain is reduced which can lead to problems with memory, thinking and behavior), muscle weakness, and lack of coordination. Record Resident #4's admissions MDS dated [DATE] revealed a BIMS score of 05 which meant severe cognitive impairment.Record review of Resident #4's care plan dated [DATE] revealed she had impaired cognition, ADL deficit and was a smoker.Record review of Resident #4's assessments revealed an Elopement Assessment was updated on [DATE] and revealed upon admission, she had desire to return home but no longer voices desire to return home. Resident does not aimlessly wander the facility and is able to ambulate independently without any assistive devices. Resident aware of smoking schedule and utilized sign out log when leaving the facility with friend.Record review of Resident #5's face sheet, dated [DATE], revealed a [AGE] year-old man who was admitted to the facility on [DATE]. His diagnoses included: Cerebral Infarction (stroke), Type 2 Diabetes and Depression. Record review of Resident #5's quarterly MDS dated [DATE] revealed a BIMS score of 13 which meant his cognitive function was intact.Record review of Resident #5's care plan dated [DATE] revealed he had visual impairment, was a fall risk and had impaired cognitive function.Record review of Resident #6's face sheet, dated [DATE], revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included: Major Depressive Disorder, Malignant Neoplasm of unspecified Kidney (cancerous kidney tumor), COPD, Acute Stress Reaction and Repeated Falls.Record review of Resident #6's quarterly MDS dated [DATE] revealed a BIMS score of 03 which meant severe cognitive impairment.Record review of Resident #6's care plan dated [DATE] revealed she was a fall risk, had impaired visual functioning, had anxiety, and impaired cognitive functioning.Interview on [DATE] at 9:57 a.m. with the DCO while the EDO and the ADON were present, revealed there were canine units looking for Resident #1 and they found her back off in the creek near the service road of Hwy 75 and was less than a mile from the facility. She stated on [DATE], a nurse found Resident #1 trying to put in the door code to go out to smoke. The DCO stated the nurse told her it was not time to smoke. The DCO talked to Resident #1 on the morning of [DATE]. She stated the FSA-A was supervising the 6:30 p.m. smoke break on [DATE]. The DCO stated FSA-A told her he thought Resident #1 had come back in the building with the residents she was sitting with during the break. The DCO stated the smoking area was not enclosed. She stated the facility did have cameras and Resident #1 could be seen at 6:28 p.m. on [DATE] walking into the dining area. She stated several residents stated Resident #1 was at the smoke break at 6:30 p.m. The DCO stated the cameras never showed Resident #1 coming back into the building. The DCO stated the police had 5 canines and [NAME] searching for Resident #1. She stated the police found her last night by the creek area and they got a call around 9:30 p.m. letting them know.Interview and observation on [DATE] at 10:10 a.m. with the DCO revealed she had made a smoke break log she was about to implement. The DCO showed surveyor the log in sheet which had each smoker's name on it, times and check in and check out for each resident.Interview on [DATE] at 10:45 a.m. with Resident #2 (roommate of Resident #1) stated she did not know what happened to Resident #1. She stated Resident #1 left yesterday. Resident #2 stated Resident #1 had brain surgery in the past, had problems with her stomach, and cried saying she wanted to go home about a month ago. Resident #2 stated there were no issues with anyone getting out before. She stated Resident #1 did not take any of her clothes. Resident #2 stated there was always a staff member outside with them on smoke breaks.Observation on [DATE] at 11:03 a.m. of smoking break revealed HK-A put in door code to allow residents out into the smoking area. He distributed cigarettes and lit residents cigarettes for them. Observed 4-foot property line chain link fence at the back of the smoking area but no gate/fence on either end of the building. Interview on [DATE] at 11:04 a.m. with HK-A stated he would hand out cigarettes and light cigarettes. He stated the fence at the back of the smoking area was open at both ends of the building. The HK stated they have scheduled times to take residents out for their smoke breaks. He stated staff were supposed to stay outside with the resident while they were smoking. The HK stated he paid attention to who comes out and sits by the trees. He was not working on [DATE], the day Resident #1 left the facility. The HK has never heard of any resident walking off before. He stated the residents did not know the door codes. Interview on [DATE] at 11:14 a.m. with CNA-A stated Resident #1 slept a lot and was mostly independent. She stated Resident #1 was usually in her room except for smoke breaks. CNA-A stated Resident #1 used the bathroom and would shower and dress independently. CNA-A said she was shocked when she heard Resident #1 had left as she was not exit seeking. CNA-A stated for a missing resident, she would immediately notify her nurse, they would look for the resident inside and around the perimeter and call the police if not found.Interview on [DATE] at 11:34 a.m. with Resident #4 stated she did not know if she was friends with Resident #1. She stated she went out for every smoke break. Resident #4 stated she had never seen any resident walk off from smoke break. She stated there were always staff outside with them during the smoke break.Interview on [DATE] at 11:38 a.m. with Resident #5 stated, on [DATE], when they were waiting to go in from smoke break, as staff were helping people in over the door hump, he saw Resident #1 go around the corner. Resident #5 stated he did not tell the staff because he did not think anything about it. Resident #5 stated he thought she was just looking at something and that she would come in with the rest of them. He stated nothing like that had happened before. Resident #5 stated Resident #1 acted fine, like herself.Interview on [DATE] at 11:40 a.m. with Resident #6 stated she found out she and Resident #5, were the last ones to see Resident #1 on [DATE]. Resident #6 stated Resident #1 was her friend, and she usually talked to her and told her things but Resident #1 gave no indication of anything.Email sent on [DATE] at 1:46 p.m. sent to the Police Department requesting a copy of the police report regarding Resident #1.Interview on [DATE] at 2:28 p.m. with [NAME] President of Operations/the VPO, stated he was looking into getting a fence to secure the back sides of the smoking area. He stated he would be getting an estimate from a fence company tomorrow, [DATE] or on [DATE]. The VPO stated the fence company would have to get permits from the city before they would be able to start building the fence. The VPO stated there was a chaplain and a grief counselor coming today. He stated the facility had the new head count sheets for the smoking area. The VPO stated the DCO was reassessing all the elopement assessments. The VPO stated the FSA was initially suspended pending investigation, but he would be terminated.Interview on [DATE] at 3:39 p.m. with the DCO while the ADON was present, stated the last elopements the facility had were [DATE] when a resident went out into the front patio, staff got him back inside immediately and he was immediately transferred to a male locked unit at another facility. The other elopement they had was on [DATE] when a resident forgot to sign out when he went around the corner with a locksmith to get his car unlocked. The DCO stated the facility was having a chaplain come today and tomorrow, the psychiatric doctor would be at the facility on [DATE] and was opening her services to anyone in the facility that wanted to speak with her. The DCO stated Resident #1 left without any of her personal items except her phone. She stated Resident #1 took her watermelon cup with her everywhere, even to smoke breaks but the cup was still in her room. Interview on [DATE] at 4:24 p.m. with the DCO stated she did Elopement Assessments upon admission, every quarter and anytime there was a decline in condition or an increase in wandering.Interview on [DATE] at 5:24 p.m. with DCO stated the police told her they found Resident #1 down in a creek through a field and down a 15-foot drop. She stated the police did not say if there was any blunt force trauma or anything, just that she was found. The DCO stated Resident #1 was able to sign herself out to leave the facility, but she never did. She stated Resident #1 had no family other than two family members who were both in prison. The only contact name they had was for the RP and he was a neighbor to where Resident #1 used to live. The DCO stated the police told her they pulled camera footage off of a Ring camera from the neighborhood behind the facility and got footage of her walking. She stated that helped the police track the direction she went. The DCO stated they offer their residents at least 15 minutes for smoke break.Interview on [DATE] at 9:15 a.m. with the DCO while the ADON was present stated the fence company came at 8 a.m. and another one was supposed to come at 9 a.m. or 12 p.m. The Admin. was getting a quote and getting the process started.Observation on [DATE] at 9:27 a.m. of smoking area revealed no residents outside. Interview on [DATE] at 9:28 a.m. with Resident #2 stated neither she nor anyone else had been locked out in the smoking area.Interview on [DATE] at 9:30 a.m. with Resident #4 stated she nor anyone else had ever been locked outside in the smoking area.Interview on [DATE] at 9:32 a.m. Resident #5 (Resident #6 not in room) said he nor anyone else had ever been locked outside in the smoking area.Interview on [DATE] at 9:38 a.m. with the Detective assigned to Resident #1's case. He stated he told records to send a copy of the report to surveyor but said it would only be the missing person report right now. The Detective stated Resident #1 was within a mile of the facility, it appeared she walked down the street and looks like she fell down a 20 - 30-foot creek embankment. He stated he did not notice any foul play, and appeared Resident #1 had just wandered off. The Detective stated that from appearances, Resident #1 probably wound up down the creek embankment quickly after leaving the facility. He stated a facility staff stated the resident had gone back inside with all the other residents. The Detective stated it would take weeks for the physiological nature of her death, but the final autopsy report had to wait for the toxicology report before making an official ruling which could take months. He stated Resident #1 was not in the water and the creek embankment had a bunch of tree roots and her body was intertwined around them.Interview on [DATE] at 10:05 a.m. with the VPO stated a fence company was out this morning and once they get the bid, the facility will give them payment. He stated once the fence company gets the city permits, the fence company stated it would take about 3 days to complete the fencing. The VPO stated they were putting in a 6-foot privacy fence.Interview on [DATE] at 10:10 a.m. by phone with FSA-A stated he was assigned the smoke break at 6:30 p.m. and he thought he remembered Resident #1 coming back in. He remembered Resident #1 was out of cigarettes and Resident #5 gave her one. FSA-A stated he saw Resident #1 sitting on the back wall with a group of women including Resident #4. He stated he saw the group of women Resident #1 was sitting with go back inside and thought she had gone back in with them. FSA-A stated he left the residents back in from smoke break at 7 p.m. FSA-A stated during smoke break, he would hand each resident 1 or 2 cigarettes, light their cigarette/s for them and watch them. He stated he did not realize Resident #1 had gone around the corner when everyone was going back in. FSA-A stated he got suspended pending investigation and the facility just called right before the surveyor called to let him know he was terminated.Email on [DATE] at 10:15 a.m. from the police department's records department which stated they were waiting for a correction to the police report regarding Resident #1 before the police report could be sent.Interview on [DATE] at 11:32 a.m. with VPO stated he was given an estimate of the cost of the fence and said he was going down to the bank to get a check and to make a partial payment. He gave surveyor a copy of the estimate and a map with the fence lines in place.Interview on [DATE] at 1:01 p.m. by phone with the LVN stated on [DATE], she was sitting at the nurse's station and the other nurse with her saw Resident #1 go across the hall to another room (not occupied). The LVN stated she went to check on her, and Resident #1 was just looking out the window with a few personal items in her hands. The LVN asked what she was doing and she said she was just looking and did not want to disturb her roommate who was sleeping. She stated she believed it was the next night and one of the residents or a CNA told her Resident #1 was at the back door to the smoking area trying to put in the door code. The LVN said Resident #1 was not doing it when she checked and had gone back to her room.The LVN stated on [DATE], she was still getting her reports from the previous shift nurses when the residents had their smoke break at 6:30 p.m. She stated she had not had a chance to do her rounds yet. The LVN stated at the end of the 8:30 p.m. smoke break, around 9 p.m. a CNA told her Resident #1 was missing. The LVN stated they started their search of the rooms and she called the DCO. She did not get an answer from the DCO, so she called the on-call number, and she started searching for Resident #1. The LVN stated Resident #1 stayed in her room often and did not have any exit seeking behaviors other than looking out the window. She stated Resident #1 did all her own ADL's and was independent walking. The LVN stated Resident #1 was able to sign herself out but never had. She stated the facility implemented a new checkout sheet every time the residents went out to smoke and when they came in. She stated the residents would be checked off when they went out, a headcount would be done and then the residents would be checked back in when they were done with smoke break. She stated they facility did in-service trainings on missing person, elopement, and smoking policy.Observation on [DATE] at 1:31 p.m. of smoke break revealed HK-A staff checking off each resident prior to giving cigarettes and checking to make sure his head count matched. He put the key code in for the door and allowed residents to exit into the smoking area and did another head count. Interview on [DATE] at 1:31 p.m. the HK-A stated he would check everyone off when they come out, do a head count and then check each resident off as they go back inside the building.Record review of the facility's Smoking Policy, dated [DATE] revealed It is the policy of this community to accommodate residents who desire to smoke, including electronic cigarettes by taking reasonable precautions, providing a safe environment for them and protecting the non-smoking residents.Record Review of the facility's Smoke Break Monitoring dated [DATE] revealed During smoke breaks, scheduled employees must be outside in line of sight of all residents that are smoking. No residents are allowed outside of vision of employees (i.e.: around the corner of the smoking area).Record Review of the facility's Elopement policy, dated [DATE], revealed under Policy:To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing.On [DATE], an Immediate Jeopardy was identified. On [DATE] at 2:51 p.m. the facility; the EDO, the DCS and the VPO were notified at that time of the Immediate Jeopardy, and a Plan of Removal was requested.The following Plan of Removal submitted by the facility was accepted on [DATE] at 5:15 p.m. Review of the IJ plan of removal reflected: This letter serves as the Plan of Removal for the Immediate Jeopardy identified at.(the facility) on [DATE], at 2:51 p.m. The corrective actions outline below have been implemented to address the alleged deficient practices.Resident #1 was located by.police department on [DATE] at approximately 9 p.m.Resident #1 was deceased upon discovery.On [DATE], at approximately 9:30 p.m. after failed search efforts, the facility contacted local law enforcement regarding Resident #1's absence. Director of Operations (DCO) arrived at the facility at approximately 10:00 p.m. to assist law enforcement in search efforts. DCO gathered all staff statements regarding the last known visual of Resident #1 on Juley (sic) 6, 2026. DCO gathered statements from the residents that participated in the 6:30 p.m. smoke break on [DATE]. Upon gathering statements from staff and residents, last known visual of Resident #1 was at the 6:30 p.m. smoke break.Employee assigned to the 6:30 p.m. smoke break was suspended [DATE], pending investigation.On [DATE], following the arrival at 10 p.m., DCO initiated staff re-education regarding Exit Seeking behavior. On [DATE], at approximately 7 a.m. DCO initiated Smoke Break monitoring with 100% of assigned team members responsible for smoke break monitoring. On [DATE], at approximately 10:30 a.m., DCO re-educated all staff regarding the Elopement Binder, location, and contents. On [DATE], at approximately 9:30 a.m. CDO, implemented and educated all staff responsible for monitoring smoke breaks a head count check in/out log to ensure all residents exit and re-enter the community for future smoke breaks.On [DATE], at approximately 9:30 a.m. DCO conducted and completed 100% of the facility elopement assessments. Elopement binder was updated to reflect any abnormal findings on [DATE]. On [DATE], upon completion of the elopement assessment audit, Clinical Reimbursement Coordinator (CRC), updated all changes based on any updated findings.On [DATE], Maintenance Director arrived at the community at approximately 11:20 p.m. and re-coded all keypad entries and exits.On [DATE], at approximately 8 a.m., Maintenance Director contacted fencing vendor to schedule a time to completed a quote to secure the smoking area. On [DATE], at approximately 8 a.m., fence vendor arrived on site to complete quote for the facility. On [DATE], at approximately 11:32 a.m. the facility received and approved the quote for the fence to secure the smoke area at the facility. Fence project approved with down payment on [DATE]. Fence project pending permit review and approval from the City. Permit request submitted to the City at 3:19 p.m. on [DATE].All education was completed [DATE], at 5 p.m.The Medical Director was notified of the Immediate Jeopardy on [DATE], and participated in development of this plan through an abbreviated Quality Assurance process. The next scheduled QA meeting is set for [DATE], at 12:00 p.m.This Plan of Removal was implemented on [DATE], and compliance will be monitored through direct observation by the Executive Director of Operations and the Director of Clinical Services.Observation on [DATE] at 5:30 p.m. the Elopement binder which had every resident in the building in alphabetical order, with elopement ratings high, medium, or low, a face sheet and a colored photograph of each resident in the binder.Observation on [DATE] at 5:40 p.m. of in-services on:[DATE] on Identifying and Recognizing Exit Seeking Behaviors by all staffXXX[DATE] on Elopement Policy & Procedures and Elopement Binder for all staff.7/7 - [DATE] on Smoke Break Monitoring: and New Smoking Monitoring Log completed by smoke break staff.Observation and interview from [DATE] at 9:50 a.m. - [DATE] at 6:57 p.m. multiple staff trying to remember the numbers for the door codes and stating all the codes had just been changed.Observation on [DATE] of fence company quote and initial payment receipt for the fence around the smoking area.Interviews between [DATE] at 9:50 a.m. - [DATE] at 6:57 p.m. with staff members HK-A, CNA-A and the LVN revealed they had in-service trainings over elopement policy and procedures, the smoking monitoring log, the elopement binder and identifying and recognizing exit seeking behaviors. Each staff was able to explain their responsibility when a resident eloped or was missing. Staff knew smokers were to be logged out when residents went out for a smoke break, do a head count and then log the residents back in one by one when they re-entered the building. All staff were consistent that resident should never be left unattended in the smoking area.Observation on [DATE] at 6:30 p.m. of smoke break revealed FSA-B checked off resident's names and gave them cigarettes prior to going outside. FSA-B did a head count to ensure his number of checked off residents matched. Observed FSA-B checked off residents when they went back inside the building.Interview on [DATE] at 6:47 p.m. with FSA-B stated he would check resident's off as they came out and do a head count to make sure his numbers matched. He stated he would check each resident off when they went back inside. FSA-B stated he was always out with the resident during their smoke break. He stated if he needed to go inside for any reason, he would get another kitchen staff to come out so residents were never left unattended.On [DATE] at 5:15 p.m., the EDO, the DCO, the ADON and the VPO were notified the IJ was removed. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that was not immediate jeopardy because the facility's need to evaluate the effectiveness of its corrective systems.

Based on observation, interview, and record review, the facility failed to ensure full visual privacy for residents for 3 of 12 rooms (rooms [ROOM NUMBER]) reviewed for physical environment. The facility failed to ensure rooms [ROOM NUMBER] had privacy curtains installed to provide privacy for the residents. This failure placed residents at risk for no visual privacy during care which could cause decreased feelings of self-worth. Findings included:Observation on 01/31/26 at 9:15 AM revealed room [ROOM NUMBER] did not have a privacy curtain for Bed B, and there was no track installed on the ceiling for a privacy curtain to be hung. Observation on 01/31/26 at 9:20 AM revealed the privacy curtain for Bed B in room [ROOM NUMBER] was positioned over the window due the window not having a curtain. This left the end of Bed B exposed. Observation on 01/31/26 at 9:40 AM revealed room [ROOM NUMBER] did not have a privacy curtain for Bed B although there was track on the ceiling for a privacy curtain to be hung. Interview on 01/31/26 at 2:11 PM with the Activity Director revealed privacy was important for the dignity of the resident and it was just respectful to protect it. She stated it was important to protect residents' dignity for their self-esteem. Interview on 01/31/26 at 2:15 PM with LVN A revealed privacy and dignity were important for all residents for their self-esteem. She stated the facility was their home, and they deserved to feel comfortable in their environment. Interview on 01/31/26 at 2:18 PM with CNA B revealed protecting the residents' privacy included keeping them from being exposed to other residents, and it was important for their dignity and self-esteem. Interview on 01/31/26 at 2:35 PM with RN D revealed the residents had a right to their privacy and protecting their dignity helped the residents feel safe and helped their self-esteem. Interview on 01/31/26 at 2:40 PM with CNA E revealed privacy and dignity were important for the residents to let them know they were still valued. She stated requests for repairs were placed in the maintenance logbook. Interview on 01/31/26 at 2:44 PM with CNA F revealed she had not noticed the lack of curtains on the 100 Hall. She stated maintenance was responsible for hanging the curtains. She stated repair requests were placed in the maintenance logbook. She stated privacy for the residents was important, so they could change or receive care without being observed by other residents. Interview on 01/31/26 at 3:10 PM with the ADON revealed each resident deserved to be treated with respect and dignity which included protecting their privacy. She stated the facility was their home and staff needed to remember that. An interview was attempted on 01/31/26 at 3:20 PM with the Director of Plant Operations via telephone; however, the attempt was unsuccessful. Record review of the facility's Quality of Life- Homelike Environment, dated May 2017, reflected the following: Residents are provided with a safe, clean, comfortable, and homelike environment.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity for 2 of 6 residents (Residents #1 and #) reviewed for resident rights. 1. The facility failed to ensure Resident #1 was not exposed while in a public area of the facility. 2. The facility failed to ensure Resident #2's urine collection bag had a privacy cover. These failures could cause the residents to become embarrassed and have lowered levels of self-esteem. Findings included:1. Record review of Resident #1's quarterly MDS assessment, dated 01/21/26, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia, diabetes, and heart failure. The MDS reflected the resident severe cognitive impairment with a BIMS score of 7, she used a wheelchair for mobility, and she was totally dependent on staff for her ADLs, including lower body dressing. Record review of Resident #1's care plan, dated 11/20/25, reflected she had an ADL self-care deficit, and was incontinent of bowel and bladder. Observation and interview on 01/31/26 at 9:00 AM revealed Resident #1 was by the front door, in the main lobby in a reclining chair, watching television. The resident had a blanket that had been moved to the side of the chair, and she was not clothed from the waist down, leaving her brief exposed. The resident was asked if she wanted to cover up, which she replied she did not want to cover up. When asked about her pants, she stated she did not need them. Observation on 01/31/26 at 12:05 PM revealed Resident #1 was sitting in the dining room eating her noon meal, still in her reclining chair, with her left leg exposed up to her hip with her brief exposed. Other residents were observed in the immediate area around the resident. 2. Record review of Resident #2's quarterly MDS assessment, dated 01/11/26, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included kidney failure, complications of indwelling urinary catheter, and Parkinson's disease. The MDS reflected that the resident had moderate cognitive impairment with a BIMS score of 9, and he was dependent on staff for most of his ADLs. Record review of Resident #2's care plan, dated 12/19/25, reflected he had bladder incontinence and had an indwelling catheter, and he had an ADL self-care deficit. Observation on 01/31/26 at 12:08 PM revealed Resident #2 was eating his noon meal in the main dining room. His urine collection bag was hanging from his wheelchair and did not have a privacy cover. Interview on 01/31/26 at 2:11 PM with the Activity Director revealed respect was important for the overall dignity of the resident, and it was just respectful to protect it. She stated it was important to protect the resident's dignity for their self-esteem. Interview on 01/31/26 at 2:15 PM with LVN A revealed respect and dignity were important for all residents for their self-esteem. She stated the facility was their home, and they deserved to feel comfortable in their environment. Interview on 01/31/26 at 2:18 PM with CNA B revealed protecting the residents' right to privacy included keeping them from being exposed to other residents, and it was important for their dignity and self-esteem. Interview on 01/31/26 at 2:24 PM with CNA C revealed all residents deserved to be respected and have their privacy and dignity protected because they were still people and should be treated like family. Interview on 01/31/26 at 2:35 PM with RN D revealed the residents had a right to their privacy and protecting their dignity helped the residents feel safe and helped their self-esteem. She stated she had observed Resident #1 exposed in the main lobby and put her blanket back over her. She stated she educated the resident on keeping herself covered. She stated Resident #1 did what she wanted, and if she did not want to do something, there was no convincing her to do it. Interview on 01/31/26 at 2:40 PM with CNA E revealed respect and dignity were important for the residents to let them know they were still valued.Interview on 01/31/26 at 3:10 PM with the ADON revealed each resident deserved to be treated with respect and dignity which included protecting their privacy. She stated the facility was their home, and staff needed to remember that. She stated she was not aware Resident #1 had been out and about without a privacy cover on his urine collection bag. She also did not know Resident #1 had exposed herself by pulling off her blanket. She stated Resident #1 should have been fully dressed. Record review of the facility's Resident Rights policy, dated December 2016, reflected: Employees shall treat all residents with kindness, respect, and dignity.The resident has a right to:a. a dignified existenceb. be treated with respect, kindness, and dignity.

Based on observation, interviews, and record review, the facility failed to ensure resident call lights were answered in a reasonable time for three (Resident 1, Resident 2, and Resident 4) of three residents reviewed for resident call system. The facility failed to ensure Resident 1, Resident 2, and Resident 4's call lights were answered in a reasonable time to meet their needs with three of three residents being diagnosed with lack of coordination, muscle weakness, blindness, and wheelchair dependency for mobility. This failure could place all residents at risk of the inability to contact the nursing staff and obtain assistance when needed and maintain a dignified existence.Findings include: On 1.13.26 at 9:35 a.m. during initial facility rounds, call light panel at the nurses station was observed to have two call lights on. Observed three staff sitting at the nurse's station typing on computers with no attempt to assist residents observed. In an interview and observation on 1.13.26 at 11:57 a.m. with Resident 1 revealed he felt safe living at this nursing home. He was observed to use a wheelchair for mobility. He was observed to have his call light draped over his left shoulder and clipped to the pocket on his shirt. He stated this made his call light easier to reach while sitting up in his wheelchair. He stated call light response time varied; usually 15 to 30 minutes but sometimes up to 1 hour. He said, Let's test it. [sic]; and pressed his call light button at 11:58 a.m. Record review of face sheet dated 12.20.25 for Resident 1 revealed a male resident with the following diagnoses: muscle weakness, unsteadiness on feet, lack of coordination, hyperlipidemia; unspecified (high cholesterol level) and erosive osteoarthritis) an inflammatory type of arthritis. MDS dated 12.20.25 revealed an alert and oriented male resident able to be interviewed. MDS Section GG-functional abilities revealed Resident 1 requires minimal assistance with activities of daily living. He used a wheelchair for mobility. Care Plan dated 12.20.25 revealed Resident 1 required minimal assistance for activities of daily living like transferring, bathing and dressing. He ate meals independently. In a telephone interview on 1.13.26 at 11:06 a.m., with Floor Tech L, he stated he had worked in the laundry department, and in housekeeping. He stated while cleaning resident rooms, many residents would turn on their call light and wait for staff to answer. He stated many times it took 30 minutes to an hour or longer for the call light to be answered. He stated sometimes the resident would ask him to go get a nurse because their call light had been on for an hour and no one would come answer it. [sic] He stated he would go to the nurses' station and report the residents request but observed the call lights were still not answered timely. Observation on 1.13.26 at 11:59 a.m. revealed RN D, was sitting at the nurse's station charting on a computer. Observed no attempt to answer Residents 1's call light. In an interview and observation on 1.13.26 at 12:00 p.m. with RN D, she stated her expectations for answering resident call lights was Everyone can answer a call light. [sic] She was observed to leave the nurse's station and go to the dining room without answering the active call light for Resident 1. Observation and record review on 1.13.26 at 12:08 p.m. revealed Resident 1's call light was still activated and had not been answered. Review at 12:08 p.m. of staffing sheet dated 1.13.26 for 6:00 a.m. to 2:00 p.m. shift revealed four certified nurse aides on duty for the shift. All four certified nurse aides were observed in the dining room passing trays for the noon meal. A staff member was not observed to be assigned to answer call lights during meals. In an interview and observation on 1.13.26 at 12:18 p.m. at the nurse's station with the Facility Administrator, she stated, Everyone can answer a call light for a resident and get a nurse if needed. [sic]. The call light for Resident 1 was observed to still be active. Attention was called to the call light panel and the time the call light was activated by Resident 1 to the Facility Administrator. No answer to Resident 1's call light during this interview was observed. Observation on 1.13.26 at 12:20 p.m. revealed Resident 1's call light was answered by CMA G. The call light had been active approximately 23 minutes before being answered. Interview on 1.13.26 at 1:00 p.m. with RN DCO J said her expectations for all staff, including LVN's and RN's, responding to active call lights were that everyone can answer call lights and non-nursing staff can notify nursing if needed. When questioned if she ever observed RNs or LVN's not answering active call lights; RN DCO J stated, I've never had a RN or LVN not answer a call light. [sic] Interview and observation on 1.13.26 at 1:04 p.m. with Resident 2 stated it took anywhere from 15 minutes to one and one-half hours for call lights to be answered by staff. [sic] Resident 2 activated his call light at this time to test response time. Record review of Resident 2's MDS dated 12.27.25 revealed a BIMS score of 15 indicated the resident was alert and able to be interviewed. Under MDS section GG - functional abilities, he required minimal assistance with activities of daily living. He ambulated with a walker and used a wheelchair for mobility. Record review for Resident 2 care plan dated 12.27.25 revealed he was monitored for falls due to unsteadiness, lack of coordination, and history of having a stroke. He identified as a trauma survivor and was monitored for changes in mood and behavior with consultants and psychiatry counseling as needed. Interview on 1.13.26 at 1:20 p.m. with Resident 4 stated it took too long to get the call light answered. She stated, My family member, (Resident 2), must sometimes help me lift my legs up to get into bed. She stated she required extra assistance with many activities of daily living because she was blind. [sic] Record review for Resident 4's face sheet dated 12.27.25 revealed a [AGE] year-old female with the following diagnoses: repeated falls, myocardial infarction (heart attack), anxiety disorder, blindness left eye, low vision right eye, muscle weakness, lack of coordination, malignant neoplasm of kidney (cancer), hypertension (high blood pressure) and polyneuropathy (nerves to hands, fingers, feet and toes are damaged). Record review for Resident 4's MDS dated [DATE] revealed a BIMS score of 15 revealed resident was alert and able to be interviewed. Under MDS section GG - functional abilities, resident needed moderate assistance from another person to complete activities of daily living due to blindness and impaired visual function. She ambulated with a walker. Record review for Resident 4's care plan dated 12/27/25 revealed wound care for cyst removal to right underarm. Cleanse area with normal saline, pat dry, apply antibiotic ointment, dressing and paper tape daily and as needed. She was at high risk for falls due to blindness and impaired visual function and staff were to anticipate her needs. Observation on 1.13.26 at 1:45 p.m. revealed the call light for Resident 2 and Resident 4 had not been responded to at the end of the 45-minute interview. In an interview on 1.13.26 at 1:30 p.m. CMA G stated, Everyone could answer a call light and there was no reason for an LVN or RN to not answer call lights for residents. [sic]. She stated her expectation was a call light should be answered within ten minutes. Interview on 1.13.26 at 2:26 p.m. with CNA H stated, Everyone can answer a call light and notify a nurse if needed. She stated there was always a staff member assigned to the nurse's station to answer call lights when meals are served [sic]. She did not answer when asked who was assigned for that task on 1.13.26 at noon. On 1.13.26 at 2.27 p.m. after 10 minutes of observation attention was drawn to the call light panel with two room lights 202B and 105A activated; RN D, LVN F, and CNA H made no attempt to answer call lights. Observation on 1.13.26 at 2:45 p.m. at the nurse's station revealed the call light panel continued to have two active lights on for 202B and 105A. RN D, LVN F, and CNA H were observed sitting at the nurse's station typing on computers. No attempts to answer active call lights was observed. In an interview on 1.13.26 at 4:22 p.m. with LVN ADCO K and RN DCO J revealed the facility currently has no policy or procedure for any staff member for answering active call lights and assisting residents with needs, activities of daily living and maintaining a dignified life.

Based on observation, interview and record review the facility failed to the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation for one (Resident #4) of 10 residents reviewed for abuse and neglect. 1.The facility failed to prevent Resident #4 from neglect and possible abuse when she was fearful of Resident #13 and remained in the room when she did not know who the resident was any longer. 2.The facility failed to investigate Resident #4's concerns and allegations. 3. LVN A, LVN B, the ADON and the DON failed to recognize aa possible allegation of abuse/neglect. 4. The facility failed to identify and intervene for Resident #4. 5. The facility failed to report and protect Resident #4 from additional psychosocial harm. An Immediate Jeopardy (IJ) was identified on 05/07/25. The IJ template was provided to the facility on [DATE] at 1:43 PM. While the Immediate Jeopardy was removed on 05/09/25, the facility remained out of compliance at a scope of pattern and a severity level of no harm that is not Immediate Jeopardy due to facility continuation of in-servicing and monitoring the plan of removal. These failures could place residents at risk for not having measures in place to protect them from serious harm and mental anguish. Findings included: Record review of the facility's freedom from abuse and neglect policy, titled Abuse, dated effective 02/01/17 and revised 0/01/23, reflected: .each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement, and or Misappropriation of property. The facility staff will adhere to the policies and procedures and will follow the guidelines in the written policy and procedure. The facility administrator is the appointed Abuse Coordinator, and in his/her absence a designee will be appointed. Abuse is a willful infliction of injury or negligent, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct that would constitute an offense under penal code S 21.08 (indecent exposure) or Penal code chapter 22 (assaultive offenses), sexual harassment, sexual coercion, or sexual assault. Residents will not be subjected to abuse by anyone, including, but not limited to community staff, other residents . .Reporting/Investigation: The law requires the abuse coordinator/designee, or employee of the facility who believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect or exploitation caused by another person to report the abuse, neglect or exploitation . Investigations will focus on determining if the abuse occurred, the extent of the abuse, and potential cause(s) . The abuse coordinator with the Director of Nursing/ designee will investigate all allegations and use the appropriate forms to document the investigation and turn it in to HHS within 5 calendar days. Upon completion of an investigation, the Director of Nursing and Administrator will analyze the occurrences, and determine what changes, if any, are needed to prevent further occurrence. All documentation of investigation must be protected and made available upon request. Protection: It is utmost important that resident(s) suspected of being abused, and all other residents must be protected during the initial identification, and investigation process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm . In the event of resident-to-resident abuse, the facility will immediately protect the resident being abused and all other residents in the facility. If the initial determination is that the perpetrator is a threat to the health and safety of the residents in the facility, as determined by the attending physician/or other physician, the resident will be discharged as soon as possible. During the time that the perpetrator has not been discharged , the facility will monitor this resident one-on-one to protect all other residents. The Director of Nursing will coordinate this and set up monitoring. If a threat does not exist then an assessment will be completed, and behavior will be care planned to meet resident's needs and protect others. Record review of the inservice record dated 04/21/25 revealed the facility inserviced staff on the Long Term Care Regulation Provider Letter with emphasis on the timeliness of reporting. Review of the Long-Term Care Regulation Provider Letter, PL 2024-14 issued August 29, 2024 revealed .HHSC rules define neglect as the failure to prvide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain or mental illness. CMS defines neglect as the failure of the facility, it's employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Record review of Resident #4's Quarterly MDS, dated [DATE], reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. She had the diagnoses of dementia (loss of cognition), anxiety disorder (sudden feelings of intense worry), major depressive disorder (persistent feelings of sadness or loss of interest), bi-polar disorder (periodically intense emotional states), schizophrenia (mental health condition that affects how people think, feel and behave) and a BIMS score of 8 (moderately impaired cognition). Record review of Resident #4's care plans revised 11/17/23 revealed there was no care plan area for the resident's cohabitation and relationship with Resident #13. Further review reflected she had impaired cognitive function or thought process due to dementia, interventions included cue and reorient and supervise as needed, dated initiated 02/02/25. Further review revealed she identified as a trauma survivor with trauma category of: Serious illness, childhood trauma, neglect, psychological trauma, dated initiated 7/21/21, and interventions included ask for permission to enter resident's room . be conscious of resident position when in groups, activities, dining room to promote proper communication with others and feelings of safety .behavioral health consults as needed, psychiatrist or counselor . Record review of Resident #13's Comprehensive MDS, dated [DATE], reflected he was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE]. He had the diagnoses of dementia (loss of cognition), anxiety disorder (sudden feelings of intense worry), bi-polar disorder (periodic intense emotional states), psychotic disorder (episodes of disrupted thoughts and perceptions), and schizophrenia (mental health condition that affects how people think, feel and behave) and a BIMS score of 11 (moderately impaired cognition). Record review of Resident #13's care plan revised 10/23/23 revealed there was no care plan area for the resident's cohabitation and relationship with Resident #4. Further review reflected he had impaired cognitive function or impaired thought process due to confusion to time and a short-term memory deficit, dated initiated 09/20/18, interventions included engage in simple, structured activities, keep his routine constant, present just one thought, idea, question, or command at a time. Further review revealed he had a behavioral problem due to anxiety and had delusions including he believed he was a prisoner of war and yelled out to relieve stress, dated revised 12/19/21, interventions included .caregivers provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by, if reasonable, discuss behavior .explain/reinforce why behavior is inappropriate . Record review of Resident #4's census report revealed she moved in room [ROOM NUMBER] on 4/28/22. Record review of Resident #13's census report revealed he moved to room [ROOM NUMBER] on 01/19/23. Record review of Resident #4's progress notes reflected: Dated 04/14/25 at 6:45 AM by LVN A: .Resident stated to night shift staff, There's a man in my room! Staff attempted to redirect and inform her that he is her roommate and boyfriend [Resident #13]. Resident responded, I don't know him! Resident would not go back to her room. Resident repeatedly asked staff, How do I get out of here? Resident then sat on the couch, waiting for her ride. Resident stayed on the couch and slept. At this time, resident continuing to sleep on couch. Dated 04/14/25 at 9 AM by LVN A: Resident woke up @ 0830 (8:30am) on the couch and came to the nurse's station asking, How do I get out of here? Nurse redirected resident to her room. Resident remembered who her boyfriend was [Resident #13]. Resident came back to the nurse's station immediately after entering her room and again asked, How do I get out of here? Nurse redirected resident for a second time. Whenever resident would enter her room, she would immediately come back up to the hall to the nurse's station asking how to leave. Nurse able to redirect resident to eat breakfast. Notified DON, ADON, and MD. Resident placed on Q(every)15 min elopement monitoring. Dated 04/15/25 at 1:30 PM by LVN A: Resident has had no attempted elopement this shift. Resident did come to staff members multiple times this shift asking, How do I get out of here? Resident redirected successfully each time. Dated 04/16/25 at 12:35 PM by LVN A: Resident has had no attempted elopement this shift. Resident did come to staff members multiple times this shift asking, How do I get out of here? Resident redirected successfully each time. Resident has had continuous bouts of confusion and has had barely any appetite since being treated for UTI. N/O UA PCR to ensure that resident's UTI has fully been treated. Dated 04/16/25 at 6:28 PM by LVN A reflected the urine PCR was collected and Resident #4 did not have any signs or symptoms of distress. Dated 04/17/25 at 7:45 AM by LVN A: When delivering breakfast tray to resident, resident asked CNA, 'How far away will you be?' CNA explained that she was passing breakfast trays on the hall. Resident explained, 'That creepy man over there keeps staring at me and I just wanted to know where you will be if I need you.' Resident was referring to her boyfriend [Resident #13]. Resident has had persistent confusion past normal baseline. Pending UA PCR results for f/u on previous UTI. Resident continuing Q15 min monitoring for elopement. Dated 04/17/25 at 8:10 AM by LVN A: Resident and her boyfriend, another resident, were ambulating up the hallway and they stopped so her boyfriend could use the bathroom. When boyfriend came back, resident yelled out to nurse's station, Where did my boyfriend go? Boyfriend looked back at her and said, It's me! Resident then stated, No you're not my boyfriend! Nurse reoriented resident successfully. Dated 04/17/25 at 12:10 PM by the Director of Resident Support Services: .Resident has been experiencing increased confusion and has expressed a desire to leave the facility. Nursing staff have been consistently redirecting her during these episodes . Dated 04/17/25 at 1:27 PM by LVN A reflected Resident #4 was assessed by behavioral health services regarding increased confusion, 15 minute checks were discontinued and medications adjusted. Dated 04/23/25 at 12:09 PM by LVN A: Resident confused and does not remember her boyfriend. Resident refusing to sit with boyfriend at lunch. Dated 04/23/25 at 8:12 PM by LVN B: .Resident very confused today and could not remember boyfriend and refused to be left in the same room with him. Dated 04/23/25 at 11:23 PM by the ADON: Upon start of shift, this resident was up in dining area sitting in a chair alone. Previous shift reported that she did not want to go into the room with her boyfriend. This nurse went to speak to this resident and assisted her to her room. No issues with assisting resident to bed. This nurse spoke with resident's boyfriend/roommate and asked that he give her some time and explained that she is just confused right now. Boyfriend/roommate verbalized understanding . Dated 04/24/25 at 12:45 PM by LVN A: During lunch, resident refused to sit with her boyfriend/roommate. Resident stating he is not her boyfriend and that he is weird. Resident ate with another resident while her boyfriend/roommate ate at a different table. Resident continues to exhibit increased confusion. Resident unable to find her room or the dining room without assistance from staff. Dated 05/05/25 at 9:25 PM by LVN B: Resident was exit seeking earlier today so we implemented 15 minute checks at 9:30pm. Record review of Resident #4's Q15 elopement monitoring, start dated 04/14/25-04/17/25 reflected Resident #4 was monitored every 15 minutes. Record review of Resident #4 lab results revealed a UTI panel, dated collected 03/21/25 and reported 03/24/25, tested positive for Escherichia coli (bacteria). Further review revealed another UTI panel, dated collected 04/16/25 and reported 04/18/25, tested negative for Escherichia coli (bacteria) and positive for Staphyloccus spp (bacteria). Record review of Resident #4's physician's orders revealed the following orders: -Ciprofloxacin 500 mg, one tablet by mouth, for 10 days for a UTI, start dated 02/25/25 and end dated 04/04/25. -urine analysis PCR for follow up of previous UTI, dated 04/16/25. -Ciprofloxacin 500 mg, one tablet by mouth, for 7 days for a UTI, start dated 04/21/25 and end dated 04/28/25. In an interview and observation on 05/05/25 at 7:17 PM with Resident #4 and Resident #13 revealed she was sitting up in bed and stated she was doing well. Resident #13 entered the room and he stated that he lived with his girlfriend (Resident #4) and they were married. He stated to Resident #4 Tell her that we are married. Resident #4 looked at Resident #13 and did not reply. In an interview on 05/05/25 at 8:36 PM with MA S, she stated Resident #4 and Resident #13 were boyfriend and girlfriend and resided in the same room for years and the family was aware and they were happy together. She stated it was not a sexual relationship and had not seen the residents in the same bed for at least a year and especially with Resident #4's incontinence. She stated Resident #4 had dementia and recently had increased confusion of her surroundings and more frequent incontinence. She stated they were monitoring her frequently. In an interview on 05/06/25 at 9:14 AM with Resident #4, she stated she had a roommate who was male and she did not like it. She stated she had girlfriends and did not want a boyfriend because it made her feel uncomfortable because sometimes boyfriends were mean. She stated there was no physical or sexual contact between them, and she denied that Resident #13 harmed her in any way. She stated he liked to sit on her bed and look out the window. She stated she didn't like him and didn't want to spend time with him but was not sure why, when he was around her she felt pretty bad. She stated she felt safe at the facility. In an interview on 05/06/25 at 9:29 AM with Resident #4's responsible party revealed she had last seen Resident #4 about 2 months ago and spoke with her over the phone on 05/05/25 and was unaware that Resident #4 voiced any discomfort with her roommate, Resident #13. She stated that she spoke with staff about 10 days ago about Resident #4's advanced directives and there was no mention Resident #4 was uncomfortable with Resident #13. She stated Resident #4 had a cognitive decline in the last few months but she found it hard to believe that Resident #4 felt uncomfortable with Resident #13. In an interview on 05/06/25 at 11:48 AM with Resident #13 revealed he and Resident #4 broke up last week and they were just companions now and it was not a sexual relationship for at least a year. He stated he planned to discharge from the facility and had just purchased a helicopter. He stated he was a prisoner of war. In an interview on 05/06/25 at 10:16 AM with LVN A revealed Resident #4 and Resident #13 developed a friendship that developed into a relationship, and they eventually moved into the same room with the approval of both resident representatives. She stated Resident #4 recently had a cognitive decline and had two courses of antibiotics for a UTI and was frequently incontinent. She stated there were some days Resident #4 knew who Resident #13 was; and other days she did not know who he was. She stated that Resident #4 asked her why there was a random man in her room (Resident #13). She stated that Resident #4 would sit and waited for a ride in the lobby area and she was being monitored with 15 minute checks until the behavioral health services assessed her for a secure unit placement. She stated she remembered writing the progress notes and it was discussed in a morning meeting about possibly moving Resident #4 to a different room. She stated in the meeting it was determined if they moved her to a different room then Resident #13 would have still sought her out and if Resident #4 was placed on the secure unit, they would be able to ensure they were separated; Resident #4 had also displayed more exit seeking behaviors. She stated behavioral health services determined she was not at a high enough risk to be admitted to the secured unit and it had not been discussed again. She stated she did believe Resident #4 could have felt unsafe and Resident #13 was also upset that Resident #4 did not remember who he was. In an interview on 05/06/25 at 12:30 PM with the Director of Resident Support Services revealed Resident #4 had dementia, was confused and doesn't understand why she was at the facility, her last BIMS score was a 3 (severe cognitive impairment). She stated Resident #13 also had confusion and had a low BIMS score. She stated she spoke with Resident #4 on 05/05/25 and had not heard any concerns about Resident #13. She stated a resident who did not remember their significant other or started to call them creepy, refused to go into their room or refused to sit with each other at mealtimes was a cause of concern regarding consent and abuse and could cause a resident to physically lash out at the other roommate if they invaded their space. In an interview on 05/06/25 at 12:41 PM with the DON revealed Resident #4 had a significant change in her cognition a couple of weeks ago and was more confused, was not sure where she was and stated she wanted to leave, did not recognize nursing staff or Resident #13, they placed her on 15 minute checks and tested her for a UTI- it was positive and had to go through several rounds of antibiotics and had medications adjusted. She stated that she was not aware of the progress notes that used the words creepy or weird and only remembered they discussed Resident #4's general confusion. She stated if she had known she would be concerned with resident safety and would have intervened and temporarily moved her to ensure she felt safe, informed the Executive Director, and reevaluated any causes. She stated there was not an assessment for resident consent for relationships and there was not a policy regarding resident cohabitation or relationships and did not know if it would be something to be care planned. In an interview on 05/06/25 at 1:03 PM with the ADON revealed Resident #4 and Resident #13 had been roommates for years and it had been good for a while, they typically sat together for every meal. She stated that recently Resident #4 had a UTI and was confused about where she was and who Resident #13 was and she reoriented Resident #4 to her room and to Resident #13. She stated that there were times Resident #13 came to her and was concerned because Resident #4 did not recognize who he was and was refusing to go to their room, she told Resident #13 to give Resident #4 some time and explained Resident #4 was confused. She stated that in a morning meeting LVN A brought up possibly moving Residents #4 and #13 to a separate rooms but there were concerns that Resident #13 would go into whatever room they moved Resident #4 to. Interview revealed there was a discussion about possibly admitting Resident #4 to the secured unit . The ADON could not remember why a change was not made. In an interview on 05/06/25 at 2:35 PM with the Executive Director revealed he started working at the facility in April of 2024 and Resident #4 and Resident #14 were already established roommates and were alright, as far as he knew it was a companionship. He stated he knew that Resident #4 had confusion and did not know the details. He stated Resident #4's progress notes would be a cause for concern for possible abuse and if he had known then he would have involved the Director of Resident Support Services and at least temporarily separated the residents or offered to separate the resident. He stated that he expected staff to report concerns to him and for the DON to inform him during morning meeting of any concerns so that they know what was going on with residents and make sure the facility addressed all their needs. He stated the facility did not have a policy for resident capacity or consent or regarding resident relationships. He stated that consent concerns would be assessed as needed, when there were concerns from family or friends, or the resident then they reassessed the situation. In an interview on 05/06/25 at 2:59 PM with LVN B revealed she started working at the facility about 3 weeks ago, and staff told her Resident #4 and Resident #13 were boyfriend and girlfriend and roommates. She stated Resident #4 did not want to go into her room with Resident #13 and she told LVN B that she did not want to be in the same room as Resident #13 and that she did not know him. LVN B stated she took Resident #4 to an empty room and suggested she sleep there. She stated Resident #4 asked LVN B why would she not want to sleep in her room and LVN B replied that Resident #4 said she felt uncomfortable with her boyfriend (Resident #13). She stated she notified the oncoming shift and continued to check on Resident #4 every 15 minutes due to her elopement risk. She stated that Resident #4's comments were concerning because it showed she felt like he was a threat to her. She stated she was not aware of the progress note where Resident #4 called Resident #13 creepy and stated she would have questioned Resident #4 more on why she used the word creepy because it sounded like she felt frightened to be alone with him. In an interview on 05/06/25 at 4:49 PM with the Director of Rehabilitation revealed Resident #4 recently had a decrease in her cognition level due to a UTI and suddenly started to dislike her roommate (Resident #13) and did not recognize him. He stated that about a week ago Resident #4's wandering, confusion, and not remembering Resident #13 was brought up during a morning meeting with the department heads. He stated he suggested they move Resident #4 to another room due to dementia and the male-female dynamic and was not sure why the residents were not moved. He stated that he could not remember if the Executive Director was present at the time. In an interview on 05/08/25 at 11:55 AM with CNA H (worked all shifts) revealed Resident #4 started to not recognize Resident #13 around January 2025 and then more consistently in the past month. CNA H stated Resident #4 said things like there's a strange or weird man in her room and she didn't know who he was. She stated she took her to LVN A who reoriented Resident #4 to Resident #13 and told her that's your boyfriend- you live with him. CNA H stated sometimes Resident #4 remembered who Resident #13 was and other times she would say no, I don't know him and went to the lobby and stayed there about an hour or so then came back and did the same thing again. CNA H stated staff redirected Resident #4 with coffee, snacks, activities, smoking breaks and eventually Resident #4 went back to her own room. She stated Resident #4 did seem afraid and confused and she saw now that it could have been a sign of abuse. An Immediate Jeopardy was identified on 05/07/25. The Administrator and DON were notified on 05/07/25 at 1:43 PM of the Immediate Jeopardy. The IJ template was provided at this time and plan of removal was requested. The facility's plan of removal was accepted on 05/08/25 at 6:26 PM. The accepted plan of removal for the Immediate Jeopardy included the following: The following is a plan of removal, which has been immediately implemented at [the facility], to remedy the immediate jeopardy as a result of alleged deficient practices, which was imposed on May 7, 2025 at 1:55pm.? On 5/7/2025 at 10am [Resident #4] was removed from the same room and placed on a separate unit away Resident #13. Resident #4 placed on enhanced supervision on 5.5.25. Resident #13 was placed on enhanced supervision 5.6.25. Resident #4 and Resident #13 assessed for signs/symptoms of abuse/neglect, physical or mental, harm by Regional Director of Clinical Services. No negative findings identified. Psych service vendor contacted by Social Services and [DON] 5.7.25 to conduct off cycle visit on 5.8.25 and/or medication review for resident #4 and resident #13 who are currently already on services with this provider per physician orders. Medical Director contacted by facility on 5.7.25 to conduct on-site assessment for Resident #4 and Resident #13 on 5.8.25. On 5.7.2025 [Executive Director], [DON], [ADON], received one to one education from Regional Director of Clinical Services on abuse/neglect/exploitation/identifying and reporting, adhering and following policy and procedures, and complying with State and Federal Guidelines. [Executive Director], [DON], and [ADON] will be in-serviced on resident to resident relationships upon the development of the policy and procedure on 5.8.25, On 5.7.25 [the facility] contacted the legal team to assist with the development of a policy and procedure for resident to resident relationships. Completion date for the development and adoption of such policy and procedure will be 5.8.25. All staff will be staff in-serviced on Resident to Resident relationships on May 8, 2025 by [Executive Director/DON], and/or designee. In-service education included but not limited to, who to report suspected relationships to, facility obligations to serve residents participating in a resident to resident relationships, resident capacity and consent for relationships, and facility response when a potential relationship is identified. Facility will communicate changes in resident relationship statuses during routine morning meetings with the IDT team and clinical staff members. All staff not present at time of in-service will not be permitted back to work until in-service is complete. All staff in-serviced on abuse, neglect, and exploitation on May 7, 2025 by [Executive Director] and [DON]. All staff not present at time of in-service will not be permitted back to work until in-service and competency test is complete. Completion date 5.8.25. LVN A, LVN B, ADON, DOR and DON received one to one in-service for resident to resident relationships and abuse/neglect/exploitation identifying and reporting on 5.7.25 by Regional Director of Clinical Services. All residents with the ability to communicate interviewed by [Director of Resident Support Services] and/or designee on 5/7/2025 for potential safety concerns. Nonverbal residents assessed on 5.7.25 for signs and symptoms of abuse/neglect/exploitation. The Medical Director was initially made aware May 7, 2025 of the immediate jeopardy, and has been involved in the development of the plan to remove during an abbreviated QA (Quality Assurance).These conversations are considered a part of the QA process. All in-servicing began 5/7/2025. No staff will be permitted to work until in-serviced. Completion date for all in-servicing will be May 8, 2025. This plan was initially implemented 5/7/2025 and will be monitored, through personal observation, through completion by Regional [NAME] President of Operation, Regional Director of Clinical Services. Monitoring included: Record review of facility's resident relationship policy titled Consensual Intimate Relationships Between Residents, undated, reflected: Purpose: To establish guidelines and procedures regarding consensual intimate relationships between residents in the skilled nursing facility while ensuring the safety, dignity, and rights of all residents. Policy Statement: The facility recognizes and respects the personal rights of residents to engage in consensual intimate relationships with one another. This policy aims to provide a framework for supporting such relationships while maintaining a safe and respectful environment for all residents. Definitions: Consensual Intimate Relationship: A mutual relationship between residents that includes emotional, romantic, or sexual components, characterized by the voluntary agreement of both parties. Nonconsensual Intimate Relationship/Sexual Contact: If a resident appears to want the intimate relationship/sexual contact to occur, but lacks the cognitive ability to consent; or Does not want the intimate relationship/sexual contact to occur. Procedures: Residents will be informed of their rights regarding intimate relationships and the facility's policies. Both parties must be capable of providing informed consent, free from coercion or undue influence. Staff should assess the cognitive and emotional capacity of both residents to ensure they understand the nature of the relationship. Assessment of cognitive and emotional capacity will be assessed by either a licensed nurse, licensed social worker or psychiatrist/psychologist and will occur when a resident indicates a desire to engage in an intimate relationship or exhibits behaviors of engaging in an intimate relationship. Re-assessment of a resident's cognitive and emotional capacity who wish to continue in an intimate relationship will occur as needed or on certain changes of condition such as stroke, dementia, depression/psychiatric illnesses, illness, or other impacts such as medication(s), hearing/visual loss, and stress. Documentation of informed consent and assessment will be in the resident's electronic health record. Residents engaging in intimate relationships will be provided with adequate privacy. Staff will facilitate private spaces for such interactions, respecting residents' dignity and confidentiality. Staff will document any significant developments in the relationship, including any concerns raised by residents, family members, or staff and will intervene when appropriate to ensure the safety of residents. Monitoring included: Record review of an in-service, dated 05/07/25, reflected staff on all shifts were in-serviced on identifying abuse and neglect and reporting requirements, signed by nursing staff including the DON, ADON, LVN A, LVN B, occupational/speech/physical therapy staff and the DOR, Director of Resident Support Services, Director of Life Enrichment, housekeeping staff and the Director of Environmental Services. Record review of an in-service, dated 05/07/25, reflected an in-service on identifying and reporting abuse and neglect and resident to resident relationships was signed by the Executive Director, DON, ADON, DOR, LVN A and LVN B. Record review of an in-service dated 05/08/25, reflected staff on all shifts were in-serviced on the consensual intimate relationships policy was signed by nursing[TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 4 residents (Resident #115 and Resident #61) reviewed for accidents and hazards. 1. The facility failed to ensure adequate supervision and put measures in place to prevent Resident #115 who was at medium risk for eloping from the facility. On 03/24/25, Resident #115 eloped out of the facility and the facility was not aware the resident eloped. Resident #115 was found in his wheelchair at the intersection of the service road off a major highway. The noncompliance was identified as PNC. The IJ began on 03/24/24 and ended on 03/25/24. The facility had corrected the noncompliance before the survey began. 2. The facility failed to ensure adequate supervision and put measures in place to prevent Resident #61 from sustaining a hot liquid burn on 04/20/25 when she spilled hot coffee and sustained a second-degree burn (partial thickness burn, damages the outer and middle layers of skin. Characterized by blistering-typically heal in 7 to 21 days) to her chin and chest. The noncompliance was identified as PNC. The IJ began on 04/20/25 and ended on 04/29/25. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of potential accidents, injuries, harm, or death. Findings include: 1. Review of Resident #115's quarterly MDS assessment dated [DATE] reflected Resident #115 was a [AGE] year-old male with an admission date of 12/08/22 and readmission date of 12/05/24. Resident #115 had a BIMS of 9 indicating he was moderately cognitively impaired. He required moderate assistance with ADLs. He had no wandering behaviors and used a wheelchair for mobility. Active diagnoses included diabetes, cerebral vascular accident (stroke) and dementia (loss of cognitive functioning that interferes with daily life and activities). Record review of Resident #115's comprehensive care plan with an initialization date of 10/23/23 reflected, Resident has impaired cognitive loss related to impaired decision-making ability, is not always understood or able to understand verbal and non-verbal expression .The resident is a smoker .Interventions .Cue, reorient and supervise as needed .The resident requires SUPERVISION while smoking . Record review of Resident #115's quarterly elopement assessment completed by the ADON on 03/05/25 reflected resident was at medium risk for elopement. The assessment indicated the resident had no history of leaving the facility without supervision, had not expressed a desire to go home, no history of leaving the facility without informing the staff, and was not wander seeking. Interventions in place included exit and stairwell alarms, frequent monitoring, utilization of check in/out log, information in wander book and staff aware of resident's wander risk. Record review of Resident #115's progress notes by RN G dated 03/24/25 at 07:22 p.m. reflected, This nurse was on her lunch break, driving on [name] Street when I spotted the resident in his wheelchair being pushed by a Hispanic man who lives on the corner. This nurse put her car in park and escorted the resident to the grassed area and contacted the CNA to help assist this nurse to escort the resident back to the facility. This nurse assessed the resident for injuries once the resident was back in the building. No injuries observed at this time. VS BP 132/72, P 72, T 97.4, R 17, o2 sat 94%. Resident unable to give details as to how he got to the stop sign. Another resident stated this resident was let out the front door by a family member of another resident. MD, DON, administrator, and family member notified of the incident. One on one monitoring of the resident started and completed every 15 min. Record Review of the PIR initiated on 03/24/25 reflected, RN G completed head to toe assessment on Resident #115 with no injuries, marks or bruises noted. All vital signs in normal limits. No change in resident's behavior noted. Resident did not miss any medications or treatments Provider response .3 day follow-up by Social Worker with no change in base line behavior noted .Resident placed on one-one supervision .Facility completed Elopement drill in-Service with staff as a precautionary measure .Signs posted at exits instructing visitors to not assist others to exit the facility .Facility reported the alleged incident to TXDHHSC .Facility completed review of resident's medical record, including medications, treatment record and care plan .Completed safe survey with no other allegations reported .Investigation summary .[Resident 116] observed another resident's family member assist Resident # 115 to exit the facility .Resident had no history of elopement or exit seeking behavior .Provider action taken Post-Investigation .Resident's Care plan was reviewed by the Director of Clinical operations and updated as required. Family member was educated not to assist residents to exit the facility. Resident #115's medication reviewed by Director of Clinical operations. Elopement assessment completed on residents. Facility completed Abuse prevention in-service . Record Review of Progress notes for Resident #115 from 03/24/25 through 04/18/25 reflected the resident remained on every 15-minute checks until his discharge to another facility with a locked unit on 04/18/25. Record review of the facility census dated 05/05/25 revealed Resident #115 was not a resident at the facility. In an interview with RN G on 05/06/25 at 03:15 p.m. she stated she was working the evening Resident #115 eloped from the building. She stated he had been in the dining room eating supper and then he went out on smoke break with the other smokers. She stated after smoke break, he had come back and was in the lobby visiting which was his normal routine. She stated she took her lunch break around 06:00 p.m. and had left the building to get something to eat. She stated she spotted the resident about a block down the road being pushed in his wheelchair by an unknown male who was trying to assist him across the intersection of the service road off Highway 75. She stated she placed her car in the intersection to stop the traffic until she could push the resident off the road. She stated she called the facility and told the CNAs to come and assist. She stated Resident #115 stated he did not know where he was going. She stated she assessed him when she got him back to the facility and notified the MD, family and the Administrator and DON. She stated they placed him on one-on-one supervision. She stated they knew the door alarm and not gone off and later discovered it was the family member of another Resident in the building who had opened the door and asked him if he wanted to go outside. She stated she was not sure how the family member had the code, but stated the codes had all been changed and they had been in serviced on elopement, which included not giving the access code to anyone but staff. She stated Resident #115 had never been exit seeking prior to this incident. In an interview with MA S on 05/05/25 at 08:40 p.m. she stated she was working the night Resident #115 had left the building. She stated she had seen him in the dining room eating his dinner around 06:00 p.m. and he had gone to the front lobby which was his normal activity. She stated the next thing she heard was he was out of the building, and they were bringing him back to the facility. She stated she was told another Resident's family member had held the door open for him and let him out. She stated they had placed the resident on one-on-one monitoring, and they had changed the door code. She stated they were not allowed to give the door code to anyone. She stated the code had been changed several times since the incident with Resident #115. She stated she had received elopement training before this incident and again after the incident. In an observation on 05/05/25 at 6:10 p.m. revealed the front door was locked with code posted outside for entry. Sign posted next to the keypad alerting visitors not to assist residents in leaving the building. Upon entering the facility, the door alarm began to ring. Staff responded promptly and reset the code. Sign was posted above the inside keypad alerting visitors not to assist residents in leaving the building. In an interview with the Administrator on 05/05/25 at 07:50 p.m. he stated Resident #115 had no previous history of exit seeking or elopement. He stated he was mobile with a wheelchair. He stated when the incident occurred the staff immediately notified him after they had returned the resident to the facility. He stated he was able to look at the camera in the lobby area and observed another Residents' family member opening the door and letting Resident #115 out the front door. He stated this was also confirmed by another resident who had witnessed the family member letting Resident #115 out the front door. He stated they immediately changed the code on the doors and placed the resident on one-on-one supervision and started looking for placement in male locked unit. He stated he also educated the other Resident's family member about not assisting other residents out of the building. He stated he placed signs on both the outside of the front door and inside the front door alerting visitors not to let anyone out of the building unless they had come with them. He stated all staff were re-educated on elopement and re-instructed not to give out the access code to visitors or vendors. He stated they used to change the code monthly but had increased the frequency to daily changes and will continue to monitor compliance with staff for the next 30 days. In an interview with LVN B on 05/05/25 at 08:25 p.m. she stated she had worked here 3 weeks and was a PRN nurse. She stated she had been trained on elopement when she was hired. She stated the access codes to the front door were only to be given to staff. She stated they were responsible for letting visitors out of the building. She stated she had not had anyone exit seek or attempt elopement on her shift. She stated they did have a new admit over the weekend (05/03/25) that was moved to the locked unit because she was at risk and was making verbal comments about wanting to leave. She stated they had the resident on one-on-one supervision until they could get the necessary approvals to move her to the locked unit today (05/05/25). LVN B stated Resident #115 was discharged before she started working at the facility. In an interview on 05/05/25 at 08:30 p.m. with RN W, she stated she was a PRN nurse that had been here since December 2024. She stated she had received training on elopement upon hire and again in March 2025. She stated any exit seeking behavior they were to immediately increase the monitoring of the resident. She stated they would place the resident on one on one or q 15-minute checks until they determined if the resident needed to be placed on a secured unit. She stated she had never seen Resident #115 attempt to exit seek. She stated only staff were allowed to have the codes to the doors and were not to give the codes to the family members or vendors. She stated they were expected to round on the residents every 2 hours and CNAs round every 2 hours, so someone saw the residents at least every hour. In an interview with LVN A on 05/06/25 at 10:15 a.m. she stated Resident #115 had never exhibited exit seeking behaviors since he had been at the facility. She they do an elopement assessment on every new admission and then complete one quarterly on all the residents. She stated they had an elopement drill and in service in March. She stated anytime a door alarm goes off staff are to immediately go to the door, look outside to see if they see anyone and then come and do a head count of residents. She stated they an elopement binder at the nurse's station that has all the resident's information and contact numbers. She stated Resident #115 was let out by another resident's family member, who had the code to the front door. She stated they had since changed the codes numerous times since the incident and had informed family and vendors they were not allowed to give the code out. She stated staff were required escort family or vendors out of the front door. In an interview with the ADON on 05/06/25 at 01:15 p.m. she stated they had in serviced all the staff on the elopement protocol, which included keeping the codes to the doors confidential. She stated in the past some long term family members had to the codes to the door but stated since this incident no one was allowed the code except the staff. She stated they do elopement drills at least twice a year. She stated they had done 2 drills since the first of the month. She stated anytime a resident attempted an elopement or started asking to go home or leave the staff were to place the resident on one-on-one supervision until they determined if the resident was going to require placement in a secured unit, which was what they decided was best for Resident #115. She stated it took a few weeks to find placement for him and stated they kept him on one-on-one until he discharged . In an interview with CNA N on 05/06/25 at 03:00 p.m. she stated she was working the 02:00 p.m. to 10:00 p.m. shift on 03/24/25. She stated she had seen Resident #115 in the dining room at dinner time. She stated the resident was mobile with his wheelchair. She stated after dinner he would usually go to the front lobby and visit. She stated Resident #115 had never attempted to leave the facility. She stated she went, and assisted RN G bring the resident back to the facility. She stated the resident did not know where he was and just stated he was going for a stroll. She stated they had an elopement Inservice right after the incident and the codes to the door were changed. She stated they were instructed to not give the code to anyone other than staff. In an interview with the DON on 05/06/25 at 04:00 p.m. she stated they had re-assessed all of the residents for their elopement risk on 03/25/25. She stated they had in serviced the staff on the elopement protocol which included warning signs of residents seeking to leave and what to do when the door alarms and they initiate a search. She stated through their investigation they determined the resident had not been exit seeking but was allowed out the front door by another resident's family member. She stated the staff had been instructed they were never to give out the access code to anyone but other staff members. She stated they were currently changing the code daily to help ensure compliance. She stated they had done elopement education on 12/20/24, 01/29/25 and again on 03/25/25. In an observation on 05/07/25 at 03:40 p.m. a family member was observed going to the front door attempting to put in the code. Family member came to the nurse's station and asked if the code had been changed. LVN B informed the family member she would assist her and went and entered the code to allow the family member to exit. The family member was heard asking for the new code and was informed by LVN B they were not allowed to give out the codes to the doors, that a staff member would assist them anytime they were ready to leave to the facility. Record review of facility's policy Elopement dated 11/01/19 reflected To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing .3. The entire search process of the facility and grounds, from the time the patient/resident is missing, should be competed withing 30 minutes .6. When the patient/resident is located, the nurse completes a head-to-toe assessment. The social service designee assesses the patient/resident for emotional distress .If a resident is not located during a search of the facility, facility grounds, and immediate vicinity, and there are circumstance that place the resident health, safety, and/or welfare at risk, a report HHSC must be made as soon as the facility becomes aware the resident is missing and cannot be located . Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. Examples of criteria that put a resident at higher risk of elopement .Cognitive impairment (example: those with dementia, Alzheimer's, brain injury) Exit-seeking behaviors (example: confused resident that thinks he/she needs to go pick their kids up from the school) New admission wanting desperately to leave .History of elopement at other communities. Review of facility's policy Elopement Risk assessment dated [DATE] reflected facility will assess all patients/residents for elopement potential in order to provide a safe and comfortable living environment. PROCEDURE 1. All patients/residents are assessed on admission by a licensed nurse for elopement risk utilizing the elopement risk assessment form. 2. All patients/residents are re-assessed for elopement potential by the licensed nurse/social service designee quarterly throughout a patient's/resident's stay and with a significant change .4. The licensed nurse or social service designee completes the elopement risk assessment form and presents to the interdisciplinary team for further intervention.6. The physician and the patient/resident or the patient's/resident's representative are notified of the patient's/resident's risk for elopement and the interventions that are recommended for prevention of elopement and patient/resident safety. 7. The patient's/resident's legal representative should be contacted, if possible, to obtain all pertinent information in relation to elopement risk .10. A licensed nurse documents in the nurse's notes and behavior monitoring flow record any exit seeking behavior on an on-going basis and interventions are adjust as needed. 11. A baseline plan of care should be completed on admission and any elopement risks should be identified. The Administrator and DON was notified and provided the IJ template on 05/07/25 at 01:43 p.m. of PNC IJ. The facility implemented the following interventions: Record Review of Resident #115's comprehensive care plan with a revision date of 03/24/25 reflected, Resident is an elopement risk/wanderer and is at risk for possible injury related to impaired safety awareness and diagnosis of dementia. 03/24/25 -exited the facility .Interventions .Place 1:1 due to safety until referrals can be made if placement is needed . Record review of Staff in-services reflected on 03/25/25-Staff in serviced on elopement education including elopement drill and limiting access to the door codes. Record Review of the Facility's Assessment Scoring report dated 05/06/25 reflected all the residents in the facility, including Resident #115, had a new elopement assessment completed on 03/25/25. Record review of staff in-service reflected the staff had been in serviced on Abuse and Neglect on 03/27/25. In interviews covering all three shifts (6 AM- 2PM, 2 PM-10 PM, and 10 PM- 6 AM), revealed they had been in-serviced on preventing and responding to elopements, participated in elopement drills, knew the alert code for an eloped resident, were aware of where to find the elopement book at the nurses' station and had been instructed not give the access code to the front door to anyone other than staff and had been in serviced on abuse and neglect and were aware of the different forms of abuse and neglect and the reporting requirements. The following interviews were conducted on the following dates: *05/06/25-10:15 a.m. to 02:05 p.m. LVN A, ADON, CNA J, CNA X, CNA H, CNA Y, and CNA P *05/07/25- 03:00 to 04:00 p.m. CNA Q and the Activity Director. *05/08/25-08:15 a.m. to 03:10 p.m. CNA L, CNA Z, RN F, LVN C, LVN E and the Treatment Nurse. *05/09/25 from 5:10 AM to 5:45 a.m. LVN HH, LVN II, CNA GG and CNA JJ. *05/09/25-10:14 a.m. to 10:45 a.m. - CNA K and CNA U The noncompliance was identified as PNC. The IJ began on 03/24/24 and ended on 03/25/24. The facility had corrected the noncompliance before the survey began. 2. Review of Resident #61's admission MDS assessment dated [DATE] reflected Resident #61 was a [AGE] year-old female with an admission date of 03/20/25. Resident #61 had a BIMS of 12 indicating she was moderately cognitively impaired. She required partial to moderate assistance with ADLs. Active diagnoses included osteomyelitis of right radius and ulna (Inflammation of bone caused by infection of the 2 bones located in the forearm) and dementia (loss of cognitive functioning that interferes with daily life and activities). Record review of Resident #61's Diet order and Communication sheet dated 03/20/25 reflected an order for Regular diet, Mechanical soft (makes food softer, easier to chew). Record review of Resident #61's care plan initiated on 04/07/25 reflected, [Resident #61] have an ADL self -care performance deficit related disease process. Activity intolerance, dementia, impaired balance, limited mobility .Interventions .Bed mobility: The resident requires supervision touching assistance by 1 staff to turn and reposition in bed as necessary .Eating: The resident is able to: setup clean-up assistance . Record review of Resident #61's progress notes by LVN C dated 04/20/25 at 2:24 p.m. reflected, Resident stated wanted coffee, aide went to get coffee out of machine in the dining room, upon return resident stated, Not hot enough, make it hotter. Aide went to get another cup and returned to resident. Moment's past, resident spilled coffee onto self, some slight redness. Aide and nurse called to room, treatment nurse assessed, and provider and POA notified. Record review of Resident #61's incident report dated 04/20/25, completed by LVN C reflected, Injury type- Burn to chest and face .Resident is alert and oriented to person, place, time and situation .Predisposing situation factors .Resident difficulty to grasp cup . Record review of Resident #61's Change of Condition report by the DON on 04/20/25 at 02:30 p.m. reflected, Primary Care Provider responded with the following orders .Silver Sept Silver Antimicrobial gel (ointment used to treat abrasions and burns) BID and leave open to air. Record review of Resident #61's progress note dated 04/21/25 at 08:35 a.m. by the DON reflected, LATE ENTRY Head to toe assessment completed at this time. Redness noted to R corner of bottom lip that extends down the R side of resident's chin and neck. Redness noted to Right side of upper chest measuring 10cm x 2cm. This area has two blistered areas that appear to be in healing phase. Blister 1 measures 1.75cm X 1cm. Blister 2 measures 1cm X 0.5cm. Wound care on board. No other injuries, bruising, marks, or skin concerns noted during assessment. MD and family aware of findings. Resident has no c/o pain or discomfort at this time. All anticipated needs met. Call light within reach. Record Review of Resident #61's TAR from 04/21/2025 through 05/02/2025 reflected, Silver Sept Silver Antimicrobial Skin and Wound Gel two times a day for Wound Healing Apply to Chin, Neck, and Rt Upper Chest. Treatment was provided twice a day until wounds were healed on 05/02/25. Record Review of the facility PIR (Provider Investigation Report) initiated on 04/21/25 reflected, .Investigation summary, resident requested coffee to be heated in microwave. Resident spilled coffee on herself and had red area and small blister to lower lip and chest. Staff were instructed not to heat coffee in the microwave. Facility reviewed coffee temperature logs in kitchen, all documentation revealed proper temperatures .Post-investigation- The Director of Clinical Operations assess resident on 04/21/25 .The Director of Clinical Operations reviewed resident's mediations to ensure proper medication administration .Residents care plan was reviewed by Director of Clinical operations and updated as required .Facility completed an Abuse Prevention-in-service as precautionary measure and not reheating beverages .Facility completed Inservice with CNA L on Abuse Prevention and Proper Positioning of residents for feeding and beverages .Facility ordered air pots for coffee service on halls . Record review of Resident #61's updated care plan dated 04/21/25, reflected, Resident has current skin concerns. Burn to right side of lip, chin, and neck. Right upper chest .Interventions .Perform treatments per MD orders. Silver Sept Silver Antimicrobial skin and wound gel. Apply BID for wound healing .Keep MD and RP informed of resident's progress . In an interview with CNA L on 05/08/25 at 08:15 a.m. she stated the day of the incident with Resident #61 she had answered her call light. She stated the resident had requested her coffee be reheated, stating it was not hot enough. She stated she took it to the breakroom and placed it in the microwave for about one minute and took it back to the resident. She stated the resident had lowered the head of her bed. She stated she placed the coffee on her overbed table and told the resident it was hot, and to be sure and raise her head up before she tried to drink it. She stated the resident told her okay. She stated she left the room and a few minutes later her call light was on again. She stated she went to her room and saw where she had tried to drink the coffee without raising her head up and had spilled some down her chin onto her chest. She stated she immediately called for the nurse who came and assessed her. She stated she was in serviced after the incident and told they were not to reheat any food or drink until they were skills checked off on the proper temperature. She stated she has had that Inservice and stated coffee was not to exceed 150 degrees and food was not to exceed 165 degrees. She stated she also learned a valuable lesson and stated she would raise the resident's bed up before she left any food or drink for a resident. She stated Resident #61 was able to feed herself and she just did not think about her trying to drink the coffee with her head down. She stated the resident had a lidded cup now for her drinks. In an interview with LVN C on 05/08/25 at 02:10 p.m. she stated she was working the night of the incident with Resident #61. She stated CNA L had come a got her and told her the resident had spilled hot coffee on her. She stated she assessed her noted redness on her chin, neck, and upper chest with a few small blisters. She stated she notified the DON, and they contacted the MD and obtained orders and started treatments on her. She stated they received in-services the next day telling them they were not to reheat any food or drinks for residents until they were skills checked off on the proper food temperatures for food and coffee. She stated she had been skills checked and knew coffee was not to be over 150 degrees and food was not to exceed 170 degrees. She stated they have thermometer at the nurse's station with the temperatures posted for the staff to use when reheating items. She stated Resident #61 ate independently and just required some set up assistance. In an interview and observation of the breakroom on 05/05/25 at 06:20 pm. where the microwave was stored, revealed a locked door with a keypad. A sign posted indicating door was to be kept always locked. Interview with MA V stated the code had recently been changed on the breakroom door to ensure only staff had access to the microwave. In an observation and interview with Resident #61 on 05/05/25 at 07:00 p.m. the Resident was sitting up in bed eating her supper. No hot beverages were observed on the tray. She stated she remembered the incident that happened a few weeks ago and stated she got a burn on her collar bone. She stated she had asked the CNA to heat up her coffee and she spilled it on her when she went to take a drink. She stated the burn had healed up and proceeded to show the surveyor where the burn was. The area was observed to be healed with slight pink color noted at the burn site. Resident #61 was observed with a wrist splint on her right wrist. She stated she was right-handed and had to learn to use her left hand. She stated her left hand gets a little shaky at times, but stated she was able to feed herself. She stated the facility had provided her a cup with a lid and handles after the incident. In an interview with [NAME] T on 05/05/25 at 07:30 p.m. he stated they had been in- serviced on food temperatures and were to keep a log of the coffee temperature when it was placed in the air pots in the dining room. He stated the temperature was not to exceed 150 degrees. He stated they do not re-heat food or drinks for the residents. He stated once the tray leaves the kitchen it cannot come back into the kitchen area for reheating. He stated the nursing staff had always used the microwave in the break room for reheating items for the resident. In an interview with the Administrator on 05/05/25 at 07:55 p.m. He stated the incident with Resident #61 was the result of CNA L reheating the resident's coffee and not knowing how hot it was. He stated he immediately stopped all staff from reheating residents' food or coffee until they were all skills checked on safe food temps. He stated he also in serviced the kitchen staff to ensure they were keeping a temperature log for the coffee not to exceed 150 degrees Fahrenheit. He stated they replaced the coffee urn in the dining room with two air pots which will hold the temperature but will not continue to heat up. He stated the coffee was checked by kitchen staff every time and ensured it did not exceed 150 degrees before placed in the air pots. He stated they changed the lock on the breakroom because they were not able to change the code. He stated they can now change the code on the breakroom where the microwave is located. He stated the door was to be kept closed and always locked as well. He stated the Food Service Director in serviced and skills checked the nursing staff on proper temperatures for reheating residents' food and coffee and had placed a digital thermomotor at the nurse's desk with instructions on safe temperatures for food and drinks. In an observation and interview with Dietary Aide AA on 05/08/25 at 08:30 a.m. she was observed checking the temperature of the coffee from one of two air pots in the dining room. The temperature was 136.8 degrees. She stated they check the temperature every time they fill the air pots, and it was not to exceed 150 degrees Fahrenheit. She stated she had been in serviced about the temperatures and the logs for the coffee a few weeks ago. In an interview with the Director of Rehabilitation on 05/07/25 at 11:50 a.m. he stated they have had Resident #61 on service since she had admitted . He stated she had progressed well and could feed herself. He stated after the incident they did request a lidded cup for her since she still had some weakness in her grasp in her left hand. In an interview with the DON on 05/08/25 at 03:10 p.m. she stated CNA L received on one training on ensuring a resident was sitting up in the bed at least at a 45-degree angle before serving food or drink. She stated all the staff were told to immediately stop reheating food and drinks until they had been skills checked on checking temperature and knowing the appropriate temperature for food and coffee. She stated the Food Service Manager had conducted that in-service and training with all the nursing staff. She stated they also updated the resident's care plan and therapy had requested a lidded cup for the resident to prevent

Based on observations, interviews and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in: 1. The facility failed to ensure food items in the facility refrigerator were dated or labeled. 2. The facility failed to ensure 2 dietary staff wore facial hair coverings while preparing and serving food dinner on 5/5/2025. 3. The facility failed to ensure the grease trap on the cooking griddle was cleaned and emptied daily. 4. The facility failed to ensure broken tiles from kitchen footboard were stored away from opened food. 5. The facility failed to ensure temperatures were taken of all cooked food before serving them to residents during lunch meal service on 05/6/25. 6. The facility failed to ensure some food items were not properly sealed. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food contamination. Findings Include: Observation of refrigerator in the kitchen and interview [NAME] T on 5/5/25 revealed the following: 6:29pm *1 opened box of 15lb Platter Sliced Bacon with an unsealed plastic bag of bacon about 1/2 full opened to the air. 6:30pm *1-gallon sized plastic bag with 10 large light green leaves, without a label of its contents or date opened. [NAME] T stated it was lettuce for sandwich fixings. *1-gallon sized plastic bag with about 30 various sized hollow white circular objects without a label of its contents or date opened, [NAME] T stated they were cut onion for sandwich fixings. *1- gallon sized plastic bag with 8 red 2-inch circular items without a label of its contents or date opened. [NAME] T stated it was sliced tomatoes for sandwich fixings. 6:31pm *5inch cylinder like green object wrapped in plastic wrap without label of what the item was or date received. [NAME] T stated it was a cucumber. *1 square clear plastic container with a yellowish beige pureed and chunky items about 1/8 full of the container with no label of what it was or used by date. [NAME] T stated it was Au Gratin Potatoes but did not know when the discard date was. Observation of freezer #1 in dining area and interview with [NAME] T on 5/5/25 at 6:34pm revealed the following: *1 sealed package of approximately 35 3inch long brown tubular items with no label of what it was. [NAME] T stated they were unopened hot dogs. *1-gallon plastic bag with 8 circular 3-inch pink discs with not label of what it was or discard date. [NAME] T stated they were burger patties he had just opened and put them away. He stated he forgot to label them and date them. Observation of refrigerator in dining room and interview with [NAME] T on 5/5/27 at 6:37pm revealed the following: * four 1-gallon clear plastic jugs of brown liquids without covers that had no discard date or label of what it was. [NAME] T stated it was tea, but he did not know when it was made. * three 1-gallon clear plastic jugs of clear liquids with no covers, discard date or label of contents. [NAME] T stated they were waters. Observation of freezer #2 in dining area and interview with [NAME] T on 05/05/27 revealed the following: 6:38pm *1-gallon sized plastic bag with about 8 2-inch beige balls with black spots on them with no label or discard date. [NAME] T stated it was cookie dough but did not know when it was opened. 6:39pm *2 approximately 3lb manufacture sealed bags of various sized disc shaped tan circles with no center, without a label of contents or date received. [NAME] T stated they were onion rings but did not know when they were received. * 2 12inch disc shaped circles with orange and white shredded stuff on top in sealed plastic wrap, without a label of what they were or date received [NAME] T stated they were cheese pizzas but did not know when they were received. * 20lb of mixed vegetables in a blue plastic bag about 1/2 full, inside a box that was not sealed or closed and was opened to the air with no discard date. Observation and interview on 5/5/27 at 6:40pm of [NAME] T and Dietary Aide DD were without facial hair coverings in the kitchen while serving food and getting items from the kitchen refrigerator. Interview with [NAME] T revealed the facility had coverings for their facial hair but the coverings do nothing and proceeded to show where the coverings were at and how they looked. He stated he had asked the Director of Food Services to buy facial coverings that covered their facial hair and was pending to hear back from her. He stated the risk to the residents of serving food without covering facial hair was hair could fall in the food and contaminate it. Observation and interview on 5/5/27 at 6:43pm revealed the following: *two red tiles from the floorboard loose and leaning on the wall in the kitchen next to the serving table. *a clear square plastic cannister with a red top on kitchen shelf above prep table with about 1/3 of contents that included beige various shaped circular disc with ridges on them without a label of contents or discard date. *An opened, unsealed bag of 3-lb potato chips about 3/4s full. [NAME] T revealed that the cannister had potato chips and the opened bag of potato chips was just opened by him that day during food service. *rectangular grease trap on the cooking skillet in the kitchen with about 1/8 inch thick of black grime all around it. [NAME] T opened the grease trap tray and revealed a nearly full tray with various yellow liquids. He stated he emptied the tray daily, but the expectation was that it should be emptied after every use. He stated the last time he emptied it was the night of 5/4/25, he could not recall when the entry hole was cleaned. He stated the grime was thick in his opinion. He emptied the tray again while being interviewed. He stated the risk to the residents of not emptying the tray or properly cleaning the grease trap was potential bacteria growth and fire hazard. Observation and interview on 5/5/25 at 6:53pm of dry food storage revealed 5 red baseboard tiles stored on a shelf under a bag of unsealed onions. [NAME] T revealed he did not know the reason the baseboard tiles were put on the same shelving unit below the bag of onions because that was nasty. He stated that the baseboard tiles had been falling off in the kitchen and a work order to fix them had been submitted but they had not fixed them yet. He stated the work order was submitted on 4/29/25. Record Review of May 2025 Meal Temperature Logs revealed temperatures of all food served on 5/4/25 and 5/5/25 were not taken. Interview with [NAME] T on 5/5/25 at 6:58pm revealed he had forgotten to take the food temperatures and log them before serving dinner that day. He knew all food needed to be tempted before serving as the risk was that food may be undercooked or too hot and could make the residents sick or burn them. Interview with [NAME] T on 5/5/25 at 7:45pm revealed the Director of Food Services had informed him the kitchen had been powered washed the day prior and the tiles on the shelf in the dry food storage had come off of the kitchen footboard and they had put the tiles on the shelf so the maintenance staff could find them easily. He stated they still should not have put the dirty tile near the open food. Observation of kitchen refrigerator on 5/6/25 at 8:22am revealed the plastic bags from previous day's observation of onions, lettuce and tomatoes (sandwich fixings) were not labeled or dated when to discard. Interview with [NAME] CC on 5/6/25 at 8:22am revealed everything in the freezers and refrigerators should be dated and labeled with the date received, date opened and discard date. He took the items out of the refrigerator and threw them away. He stated the risk to the resident of not labeling and dating was they could get sick from bad food. Observation of the kitchen floor revealed the red base board tiles had been removed. Observation of lunch being served on 5/6/25 at 12:18pm revealed [NAME] CC took out a new tray of meatloaf from the oven and did not temp it before serving it to the residents. Interview with [NAME] CC on 5/6/25 at 12:25pm revealed he failed to take the temperature of the 2nd tray of meatloaf when he took it out of the oven. He stated the oven was on, so he believed it was hot, however he should have taken the temperature. The risk to the resident of not taking the temperature was the food could not be fully cooked, and the residents could get sick. Interview with Director of Food Services on 5/6/25 at 12:56pm revealed she had trained all cooking staff on dating and labeling items. She stated the items should have potentially 3 dates date received, date opened and discard date. She expected all food in the refrigerators, freezers and dry goods to have been labelled. She stated she had not known sealed items removed from their original boxes with no manufacture label needed to be labelled what it was because it was clearly visible what they were, however, would start labeling everything. The expectation for sealing opened items was they wrap up the items in the original packaging if possible and put in a sealed plastic bag, with a date opened and date discarded. The risk to the residents of not appropriately labeling items were many things to include food borne illnesses such as Salmonella poisoning and cross contamination. She was informed the aide and cook last night had no facial coverings for their facial hair and stated the facility had facial hair covering nets and would talk to staff about the reason they were not being worn. The risk to the residents of not wearing the facial hair net covering was hair could fall in the food and contaminate it. The May 2025 Temperature Log was reviewed with the Director of Food Services noted temperatures were not taken on May 4th or May 5th. She stated the expectation was temperatures should have been taken every meal, every day before serving. If staff intended to serve food the food needed to be temped before serving. She stated she checked temperature logs daily to ensure temperatures were being taken every meal and every day, however she hadn't had a chance to check the log since the weekend. She stated she would be writing up the cooks for May 4th and May 5th, as they knew temperatures had to be taken of all food. The risk of the temperatures of the food not taken before serving was the food could be raw or could be too hot and burn residents. She stated she was made aware of the tiles that were broken last week and during the deep clean and sanitization of the kitchen. She had asked the staff who were sanitizing the kitchen to move the tiles somewhere that maintenance would have been able to find them, so they put them in the dry goods storage on the shelf. She stated they should not have put the tiles in any place food was stored and had asked [NAME] T to move them last night. She stated the risk of having the footboard tiles close to opened food was cross contamination and exposure of possible bacteria to the residents' food. She stated the grease trap on the kitchen stove should be emptied and cleaned after every use. She was shown a picture of how the grease trap looked yesterday with the gunk on it and she stated it was not acceptable and would ensure staff was doing a better job cleaning it. She stated the risk of not emptying the grease trap was it was a fire hazard. Review of the facility's policy Preparation of Foods revised 1/2023 .3. Food is prepared in a sanitary manner .10. Temperatures will be documented and followed accordingly to food safety code. Review of the facility's policy Food Storage revised 4/11/2022 .6. Food removed from its original packaging will be labeled with the following: a. received date b. open date c. contents in the package .9. Opened package or leftover food it to be tightly wrapped or covered in airtight, clean containers. It should be labeled, dated with the opened or use by date .19. Safe food temperatures will be maintained at acceptable levels during food storage, preparation, holding, service, delivery, cooling and reheating .22. Food is cooked to at least 135 degrees F. Reheat foods to an internal temperature of at least 165 F 24. Check food temperatures prior to meal service. If the food temperatures are not within acceptable parameters, the food is reheated or child to an appropriate temperature .26. Food temperatures are taken and recorded at all meals . Review of the facility's policy Food Service Uniforms effective 11/01/2019 .1. Below are some guidelines on interpretation of professional: .facial hair is allowed only if beard guard is always worn while in the kitchen and during food production/service . Review of Food and Drug Administrative Food Code, dated 2022, reflected, .Chapter 3. Food Condition 3-101.11 Safe, Unadulterated, and Honestly Presented The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard.

Based on observation, interview, and record review the facility failed to ensure an effective pest control program was implemented so the facility is free of pests and rodents for one of twenty-four residents (Resident #2), the facility's only kitchen, the facility's only nurses' station, and one hall (100 hall) of five halls reviewed for pest control. 1. The facility failed to effectively treat Resident #2's room for gnats. 2. The facility failed to keep an effective pest control program so that the facility was free of gnats in the Kitchen. 3. The facility failed to ensure one hallway (100 hall) of 5 hallways where residents' rooms were located, were free of gnats. 4. The facility failed to ensure the nurses station was free from gnats. These failures placed residents at risk for cross contamination, food borne illnesses, the spread of infection and disease, and a reduced quality of life. Findings included: 1. In an observation and interview on 05/05/25 at 6:52 PM revealed Resident #2 was lying in bed with a food tray on the bedside tables, food crumbs on the bed linen and the floor, with 5 gnats flying around her and landed on the bed linen and bedside table; she stated she had noticed the gnats for a while now, was not sure what was causing them and they bothered her but she learned to live with it. She stated that the facility did treat the room for the pests, was not sure when the last time it was treated, and housekeeping cleaned her room each day. In an observation of and interview on 05/06/25 at 3:21 PM with Housekeeper EE revealed she had cleaned Resident #2's room and floor; she stated and the residents linens were clean. At this time there was one gnat flying in the room. Housekeeper EE stated Resident #2's room did occasionally have gnats and thought it was due to Resident #2 eating in bed- the gnats were attracted to food. She stated when she saw the gnats she would write it on the pest control log and then inform the Director of Plant Operations (DPO) verbally and the room would be treated for pests. In an interview on 05/09/25 at 11:57 AM with the Director of Environmental Services (DES) revealed Resident #2 ate her meals in bed and frequently spilled food that attracted small black bugs to her room. She stated that they clean Resident #2's room [ROOM NUMBER] days a week and an additional evening cleaning on Tuesday and Thursday and Fridays. She stated Resident #2's room was treated on 05/08/25 with fly bait spray. She stated meal trays that were not picked up on time or food spills would attract the gnats and when housekeeping observed those things, they notified nursing. She stated there are cleaning products available to the staff when housekeepers were not onsite. She stated it was important for a resident's room to be free from gnats because it was an environmental hazard and was unclean for a resident. 2. Observations in the kitchen on 5/6/25 during lunch meal service revealed the following: *12:15pm a gnat flying around the bread rolls. *12:18pm a gnat landed on a bread roll. *12:25pm a gnat flying around the bread rolls. Interview with the Director of Food Services on 5/6/25 at 12:56pm revealed she was aware of the issues with gnats flying around the kitchen and believed they had been coming from the drains. She stated they had been dumping bleach in the drains to help stop the gnats. She stated the facility had been fumigating monthly. The risk to the residents of the gnats flying around the food was they could land in the food and contaminate it. 3. Observation of the 100- hall on 05/7/2025 at 1:30pm revealed two gnats by the entryway of the conference room located in that hall. Interview with CNA J on 5/8/25 at 8:42am revealed she had noticed gnats in the 100- hall, by the coffee makers in the dining room and trashes this week. 4. Observation of nurses' station in the middle of the building on 5/8/25 at 9:00am revealed 3 gnats flying around the desks the nurses' desks. Review of the facility pest control service revealed Pest Management Service Agreement dated 7/2/19 .1. Services to be performed .a. perform monthly pest control service, including coordinating with Client's staff to implement an Integrated Pest Management plan, monitor and track pest issues inside and outside of the facility, addressing site issues both reported and observed .Pest control each month consists of: inspecting and treating interior pest issues including kitchen, laundry, exits, closets .e. when requested, treat a specific areas that are experiencing a particular problem . Review of facility's Pest Logs revealed reported incidents of gnats by staff on the following dates: *2/5/25 (room [ROOM NUMBER]), * 2/20/25 (nurses' station), *4/14/25 (nurses station), *4/27/25 (room [ROOM NUMBER]), *5/1/25 (building), * 5/8/25 (laundry, room [ROOM NUMBER] and room [ROOM NUMBER]), *5/8/25 (nurses station) and, * 5/9/25 (room [ROOM NUMBER]) Review of facility invoice from Perfect Pest Control dated 4/16/25 .General Comments: Upon arrival I located logbook finding no new entries at this time. I made my way to maintenance director's office to where I was told he would out at lunch. I visited with kitchen staff stating they have seen an occasional gnat. I applied a liquid residual to cracks and crevices throughout the kitchen added a foaming agent to drains and a poly a liquid residual to the bottom sides of the dish pit tables .Material: Alpine WSG .target pests: American Roaches, Gnats/Fruit/Crane . Review of facility invoice from Perfect Pest Control dated 3/11/25 revealed gnats were not addressed during the fumigation visit. Review of facility invoice from Perfect Pest Control dated 2/12/25 .General Comments: Met with MD (Maintenance Director) upon arrival, he stated he knew of nothing but has told staff to utilize the log book. I located the logbook finding 104, 304, 310 and 291 with gnats. I inspected each room and restroom finding no signs of gnats and applied an aerosol bait to walls in restroom .I also met with laundry attendant stating gnats are better but still see an occasional gnat. I applied an aerosol bait to walls Material: PT alpine pressurized fly bait .target pests: Gnats/Fruit/Crane Interview with Director of Plant Operations on 5/7/25 at 1:12pm revealed he was aware gnats being reported in the kitchen and other areas in the building and had pest control coming every time it was reported. He stated he scheduled pest control to come on 5/9/25 to spray again for gnats. Interview with CNA P on 5/8/25 8:57am revealed she had seen a couple of gnats in several of the hallways this week. Interview with Director of Nursing on 5/8/25 at 12:09pm revealed the facility had pest control come out routinely and pest control looked at the book showing when they had issues with gnats. She had not seen gnats until they were flying around a fast food item meal that was brought earlier in the break room. The risk of having gnats in the facility with residents present was issues with infection control and cross contamination. Interview with Executive Director on 5/8/24 at 12:45pm revealed staff writes sightings of pest in the pest log and pest control was asked to come out immediately. Additionally, pest control would come monthly to fumigate and would check the pest logs as well to ensure they were treating for any issues. The Director of Plant Operations would also call the pest control company as needed. The risk of having pest in the facility, particularly in the kitchen would be contamination of food. Interview with RN G on 5/8/25 at 2:30pm revealed she saw gnats on and off in patient rooms, particularly where patients were hoarding food in their room. She worked at the facility for 7 years and had seen gnats on and off. She had never seen them in the dining area. The facility's pest control policy was requested but not provided before the date and time of exit.

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 for 3 of 17 residents (Resident #47, Resident # 28, and Resident #46) observed for infection control. 1. The facility failed to ensure LVN D performed hand hygiene before and after performing Resident #47's fingerstick blood sugar on 05/06/25 and failed to perform hand hygiene after cleaning the soiled glucometer. 2. The facility failed to ensure LVN D performed hand hygiene before and after performing Resident #28's fingerstick blood sugar on Resident # 28 and failed to prevent cross contamination of the dining room table when she placed the soiled glucometer on the table after obtaining the fingerstick blood sugar on 05/06/25. 3. The facility failed to ensure CNA Q performed hand hygiene while providing incontinence care to Resident #46 on 05/07/25 and failed to ensure CNA Q performed hand hygiene before leaving the resident's room. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: 1. Record review of Resident #47s face sheet dated 05/09/25 reflected a [AGE] year-old male with an admission date of 05/20/22. Diagnoses included type 2 diabetes. An observation on 05/06/25 at 04:30 p.m. revealed LVN D was at the medication cart preparing to obtain fingerstick blood sugar for Resident #47. LVN D put on gloves and removed the glucometer from the medication cart and wiped it down with a Sani-wipe (germicidal wipe). LVN D removed her gloves and re-gloved without performing hand hygiene and entered the resident's room. After obtaining the fingerstick blood sugar, LVN D returned to the cart, removed her gloves, and put on another pair of gloves without performing hand hygiene. LVN D then retrieved the bottle of Sani-Wipes and wiped down the glucometer and placed it back in the medication cart. LVN D then removed her gloves and without performing hand hygiene pushed the cart down the hallway to the next resident. 2. Record review of Resident #28's, Face sheet, dated 05/09/25 reflected a [AGE] year-old male with an admission date of 10/25/24. Resident #28 had a diagnosis which included Type 2 diabetes. An observation on 05/06/25 at 04:45 p.m. revealed LVN D pushing the medication cart to Resident #28's room. Resident was not in his room. LVN D stated he was probably in the dining room. LVN D pushed the cart to the nurse's station and opened the medication cart to obtain the glucometer, test strip, lancet and alcohol wipe. LVN D put on gloves without performing hand hygiene and entered the dining room. Resident #28 was sitting at the table with another resident. LVN D obtained Resident #28's fingerstick blood sugar and sat the glucometer down on the dining room table while waiting for the results. Resident's blood sugar reading was 360. LVN D gathered up the glucometer, lancet and test strip and returned to the medication cart where she disposed of the lancet and test strip. LVN D removed her gloves and put on clean gloves without performing hand hygiene and retrieved a Sani-cloth and wiped down the glucometer and placed it back into the medication cart. LVN D checked the computer to determine she would need to contact the MD for orders. LVN D reached out to the physician and received an order for 15 units of Lyumjev and recheck blood sugar at HS. LVN D then performed hand hygiene and put on gloves and retrieved the insulin pen from the medication cart and dialed in the amount of insulin required (15 units). LVN D returned to the dining room where she administered the insulin to Resident #28. LVN D returned to the medication cart, removed her gloves, but did not perform hand hygiene, and wiped down the insulin pen with an alcohol wipe and returned it to the medication cart. In an interview with LVN D on 05/06/25 at 04:55 p.m. She stated she was supposed to perform hand hygiene before and after performing a Fingerstick blood sugar. She stated she did not have any hand sanitizer on her cart. She stated she knew they were not supposed to check Resident's blood sugar or give insulin in the dining room but stated Resident #28 would not have left the dining room for her to get his blood sugar. She stated she should not have laid the glucometer on the dining room table. She stated not performing hand hygiene and placing the glucometer on the dining room table crated a risk of cross contamination and the spread of germs. In a follow up interview with Resident #28 on 05/06/25 at 05:10 p.m. resident stated he did not mind having his blood sugar checked or his insulin given to him in the dining room. He stated he would have gone to his room if that was what they wanted. He stated they had taken him to the nurse's station before when he was out of his room. He stated it really did not matter to him where he was when they got his blood sugar. 3. Record review of Resident #46's Face Sheet dated 05/09/25 reflected an [AGE] year-old female with an admission dated of 05/26/25. Diagnosis included Alzheimer's. In an observation on 05/07/25 at 02:55 p.m. CNA Q entered Resident #46's room to provide peri-care. CNA Q put on gloves but did not perform hand hygiene. CNA Q uncovered resident, pulled her pants down and unfastened the resident brief, revealing resident was wet. CNA Q provided peri care, changing the surface of the wipe with each stroke. CNA Q then retrieved a clean brief from the resident's chest of drawers, while wearing the soiled gloves, and placed the clean brief under the resident and rolled the resident over and closed the resident's brief. CNA Q then repositioned the resident, covered her up and lowered the bed. CNA Q removed her gloves, gathered the trash, and left the room without performing hand hygiene. In an interview on 05/07/25 at 03:10 p.m. CNA Q stated she was supposed perform hand hygiene before and after care and before going to the next resident. She stated she was going to wash her hands when she dropped off the soiled linen. She stated she thought since she had gloves on her hands were clean. She stated she was not aware she had to change her gloves and perform hand hygiene between each glove change. In an interview on 05/08/25 at 09:30 a.m. with the DON she stated staff were to change their gloves and sanitize their hands when going from dirty to clean. She stated staff were always required to perform hand hygiene before care and after care. She stated staff were not to perform Fingerstick blood sugars or give insulin in the dining room. She stated it was a dignity issue as well as an infection control issue. She stated they do train on infection control during their skills checks and anytime they had any issues with infections in the building. She stated the risk of not adhering to the protocol was increased risk of infections. In a follow up interview with the DON on 05/08/25 at 03:00 p.m. she stated she was unable to locate skills check for CNA Q on peri-care and hand hygiene. She stated she checked her off today. She stated she was not sure how it was overlooked. Record review of the facility's policy titled, Hand Hygiene, dated October 2022, reflected, .Hand hygiene is used to prevent the spread of pathogens in healthcare settings .You should always perform hand hygiene .Before applying and after removing personal protective equipment (e.g. gloves, gown, mask, face shield/goggles) .Before and after providing any type of care .After contact with medical equipment or other environmental surfaces that may be contaminated .You must perform hand hygiene .after contact with bodily fluids, such as urine or blood .

Based on observation, interview, and record review the facility failed to label and secure drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for the facility's one (hall 600 cart) of four medication carts reviewed for storage. 1. The facility failed to ensure Resident # 28's Lyumjev Insulin (Hormone) Pen, that was used on [DATE], was dated when opened. 2. The facility failed to ensure a vial of TB PPD, that was opened and used, was dated. 3. The facility failed to ensure 5 unopened and 1 opened vial of multi-dose flu vaccine and 3 unopened and 1 opened vial of multi-dose TB PPD was stored in a locked medication room or medication cart. These failures could affect residents and staff resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications. The findings included: 1. An observation on [DATE] at 04:45 p.m. revealed LVN D obtained Resident #28's fingerstick blood sugar. Blood sugar reading was 360. LVN D checked the computer to determine she would need to contact the MD for orders. LVN D reached out to the physician and received an order for 15 units of Lyumjev (insulin). LVN D retrieved the insulin pen from the medication cart and dialed in the amount of insulin required (15 units). Observation of the insulin pen revealed no date on the pen indicating when it was opened. LVN D administered the insulin to Resident #28. LVN D returned to the medication cart, wiped the pen down with an alcohol wipe and placed it back in the medication cart. In an interview with LVN D on [DATE] at 04:55 p.m. She stated the insulin pen was supposed to be dated once it was placed on the medication cart and opened. She stated she was not sure who had opened the pen. She stated by not dating it they had no way to know how long the pen had been open. She stated the insulin was only good for 28 days once opened. She stated she should have checked to see when it was opened. She stated giving expired insulin could result in effective insulin coverage for a resident. In an interview with the DON on [DATE] at 09:30 a.m. she stated the insulin pen was to be dated once it was opened. She stated failure to do so could result in the resident receiving and expired medication which could result in ineffective treatments and uncontrolled blood sugars. 2. An observation on [DATE] at 11:40 a.m. of the Treatment nurse's refrigerator located in the unlocked shared office space of the ADON and the Treatment nurse, revealed an undated open vial of Tuberculin Purified protein derivative and 5 unopened vials of flu vaccine and 3 unopened vials of TB PPD. In an interview with the Treatment nurse on [DATE] at 11:45a.m. she stated the TB PPD had to be dated when opened. She stated once it was open it would only be good for 30 days. She stated the risk of not dating it once opened was the potential for false positive or an inaccurate test, which could lead to a missed infection. She stated whoever opened the vial was responsible for dating it. She stated the flu vaccine and TB PPD were stored in her office when she started and thought that was where it was supposed to be stored. She stated the office door was locked when they leave for the day, but otherwise it was open to anyone who wanted to come in. In an interview with the DON on [DATE] at 11:50 a.m. she stated once a multi-use vial of medication was opened the staff were required to date it. She stated when they open of vial of TB PPD it had to be dated to prevent the risk of using an expired medication which would render it ineffective and could give a false positive reading of the PPD. The DON said she had no idea the TB PPD or Flu vaccine were stored in the refrigerator in the ADON's and Treatment nurses' office. She stated it should be stored in the medication room's refrigerator where it would be secured, and expiration dates could be checked. She stated she was moving it now. Record review of the facility's undated policy titled, Appropriate storage and handling of Insulin products, reflected, .Unopened insulin may be stored in a refrigerator . Facility staff will physically write the date the vial or pre-filled syringe was opened. Once opened, the vial or syringe may be stored in a medication cart and discarded according to the manufacturer recommendations . Record review of the facility's policy titled, Administering Medications, dated [DATE], reflected, .The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container . Record review of the facility's policy titled Storage of Medications, dated [DATE], reflected, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . The nursing staff shall be responsible for maintaining medication storage .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed Medications requiring refrigeration must be stored in a refrigerator located in the drug room .or other secured locations .Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys .

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet resident needs for 7 (Resident #4, #13, #22, #28, #34, #165, #12) of 27 residents reviewed for care plans. 1. The facility failed to create and implement a care plan that reflected Resident #4's relationship and cohabitation with Resident #13. 2. The facility failed to create and implement a care plan that reflected Resident #13's relationship and cohabitation with Resident #4. 3. The facility failed to create and implement a care plan that reflected Resident #22's relationship with Resident #28. 4. The facility failed to create and implement a care plan that reflected Resident #28's relationship with Resident #22. 5. The facility failed to create and implement a care plan that reflected Resident #165's relationship with Resident #34. 6. The facility failed to create and implement a care plan that reflected Resident #34's relationship with Resident #165. 7. The facility failed to create a care plan that reflected Resident #12's need for interventions to manage her left-hand contracture. These failures could place residents at risk of receiving inadequate interventions not individualized to their care needs. Findings included: 1. Record review of Resident #4's Quarterly MDS, dated [DATE], reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. She had the diagnoses of dementia (loss of cognition), anxiety disorder (sudden feelings of intense worry), major depressive disorder (persistent feelings of sadness or loss of interest), bi-polar disorder (periodically intense emotional states), schizophrenia (mental health condition that affects how people think, feel and behave) and a BIMS score of 8 (moderately impaired cognition). Record review of Resident #4's care plan revised 11/17/23 revealed there was no care plan area for the resident's cohabitation and relationship with Resident #13. Further review reflected she had impaired cognitive function or thought process due to dementia, interventions included cue and reorient and supervise as needed, dated initiated 02/02/25. Further review revealed she identified as a trauma survivor with trauma category of: Serious illness, childhood trauma, neglect, psychological trauma, dated initiated 7/21/21, and interventions included ask for permission to enter resident's room . be conscious of resident position when in groups, activities, dining room to promote proper communication with others and feelings of safety .behavioral health consults as needed, psychiatrist or counselor . In an interview and observation on 05/05/25 at 7:17 PM with Resident #4 and Resident #13 revealed she was sitting up in bed and stated she was doing well. Resident #13 entered the room and he stated that he lived with his girlfriend (Resident #4) and they were married. He stated to Resident #4 Tell her that we are married. Resident #4 looked at Resident #13 and did not reply. In an interview on 05/05/25 at 8:36 PM with MA S, she stated Resident #4 and Resident #13 were boyfriend and girlfriend and resided in the same room for years and the family was aware and they were happy together. She stated it was not a sexual relationship and had not seen the residents in the same bed for at least a year and especially with Resident #4's incontinence. She stated Resident #4 had dementia and recently had increased confusion of her surroundings and more frequent incontinence. She stated they were monitoring her frequently. In an interview on 05/06/25 at 9:14 AM with Resident #4, she stated she had a roommate who was male and she did not like it. She stated she had girlfriends and did not want a boyfriend because it made her feel uncomfortable because sometimes boyfriends were mean. She stated there was no physical or sexual contact between them, and she denied that Resident #13 harmed her in any way. She stated he liked to sit on her bed and look out the window. She stated she didn't like him and didn't want to spend time with him but was not sure why, when he was around her she felt pretty bad. She stated she felt safe at the facility. In an interview on 05/06/25 at 11:48 AM with Resident #13 revealed he and Resident #4 broke up last week and they were just companions now and it was not a sexual relationship for at least a year. He stated he planned to discharge from the facility and had just purchased a helicopter. He stated he was a prisoner of war. In an interview on 05/06/25 at 10:16 AM with LVN A revealed Resident #4 and Resident #13 developed a friendship that developed into a relationship, and they eventually moved into the same room with the approval of both resident representatives. In an interview on 05/06/25 at 1:03 PM with the ADON revealed Resident #4 and Resident #13 had been roommates for years and it had been good for a while, they typically sat together for every meal. In an interview on 05/06/25 at 2:35 PM with the Executive Director revealed he started working at the facility in April of 2024 and Resident #4 and Resident #14 were already established roommates and were alright, as far as he knew it was a companionship. In an interview on 05/06/25 at 2:59 PM with LVN B revealed she started working at the facility about 3 weeks ago, and staff told her Resident #4 and Resident #13 were boyfriend and girlfriend and roommates. 2. Record review of Resident #13's Comprehensive MDS, dated [DATE], reflected he was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE]. He had the diagnoses of dementia (loss of cognition), anxiety disorder (sudden feelings of intense worry), bi-polar disorder (periodic intense emotional states), psychotic disorder (episodes of disrupted thoughts and perceptions), and schizophrenia (mental health condition that affects how people think, feel and behave) and a BIMS score of 11 (moderately impaired cognition). Record review of Resident #13's care plan revised 10/23/23 revealed there was no care plan area for the resident's cohabitation and relationship with Resident #4. Further review reflected he had impaired cognitive function or impaired thought process due to confusion to time and a short-term memory deficit, dated initiated 09/20/18, interventions included engage in simple, structured activities, keep his routine constant, present just one thought, idea, question, or command at a time. 3. Record review of Resident #22 Quarterly MDS, dated [DATE], reflected she was a [AGE] year-old female admitted on [DATE] with the diagnoses of dementia (loss of cognition), heart disease, and anxiety disorder (intense worry or fear). She had a BIMS of 2 (severely impaired cognition) and moderate difficulty hearing. In an interview on 05/06/25 at 3:24 PM with Resident #22 she stated she was happy in a relationship with Resident #28 and had no concerns. She stated she felt safe at the facility. Record review of Resident #22's care plan revealed there was no care plan that addressed her relationship with Resident #28. Further review revealed she had impaired cognitive function and loss of memory, times sense, and impaired decision-making abilities and was not always understood or able to understand verbal and non-verbal language, dated revised 1/21/25. Interventions included cue, reorient and supervise as needed .keep the resident's routine consistent .break tasks into one step at a time . 4. Record review of Resident #28 Comprehensive MDS, dated [DATE], reflected he was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE], with the diagnoses of epilepsy (seizures), unspecified affective mood disorder (mood disorder), and nerve pain. He had a BIMS score of 8 (moderately impaired cognition). In an interview on 05/08/25 at 10:05 AM with Resident #28 revealed he and Resident #22 were in a consensual non-sexual relationship and staff were aware and he felt treated with respect and dignity. He stated that their relationship was important to him because it made him feel young and happy. Record review of Resident #28's care plan revealed there was no care plan that addressed his relationship with Resident #22. Further review reflected he had impaired cognitive function and loss of memory, times sense, and impaired decision-making abilities due to dementia and was not always understood or able to understand verbal and non-verbal language, dated revised 1/23/25. Interventions included cue, reorient and supervise as needed .keep the resident's routine consistent .break tasks into one step at a time . 5. Record review of Resident #165's Comprehensive MDS, dated 04.28.25, he was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of heart failure, kidney disease, and depression (loss of feelings of sadness or loss of interest). He had a BIMS score of 15 (intact cognition). In an interview on 05/08/25 at 9:45 AM with Resident #165 he stated he had been in a consensual, non-sexual relationship with Resident #34 for about 6 months. He stated that he got Resident #34 flowers from the store yesterday. He stated that the relationship was important to him because he didn't feel alone. He stated he felt safe at the facility and his rights were respected. Record review of Resident #165 care plan revealed there was no care plan that addressed his relationship with Resident #34. Further review revealed he was at risk for a self-care deficit and ineffective coping due to the diagnosis of depression, dated initiated 12/27/24, interventions included: .administer medications as ordered .provide care in a warm and caring manner .encourage resident to be an active participant in decision making . 6. Record review of Resident #34's Quarterly MDS, dated [DATE], reflected she was a [AGE] year-old female, admitted to the facility on 02/04/24 and readmitted on [DATE], with the diagnoses of mild dementia (loss of cognition) with anxiety (intense worry or fear), and idiopathic chronic gout (a form of arthritis). She had a BIMS score of 12 (moderately impaired cognition). In an interview on 05/08/25 at 10 AM with Resident #34 she stated she was in a consensual, non-sexual relationship with Resident #165. She stated she felt safe at the facility and that her rights were respected at the facility. Record review of Resident #34's care plan revealed there was no care plan that addressed her relationship with Resident #165. Further review revealed she had impaired cognitive function and loss of memory, times sense, and impaired decision-making abilities due to dementia and was not always understood or able to understand verbal and non-verbal language, dated intiated 02/21/24. Interventions included cue, reorient and supervise as needed .keep the resident's routine consistent .break tasks into one step at a time . In an interview on 05/06/25 at 12:41 PM with the DON she stated Resident #4 and Resident #13 had already established a relationship and were living in the same room when she started working at the facility in November of 2023. She stated she was aware that Residents #22, and #28, Residents #165, and #34 were in relationships. She stated Resident #22 and Resident #28 had slightly impaired cognition and the family had provided consent for the relationship, they did not reside in the same room. She stated that she saw Resident #165 with his hand around Resident #34's shoulder when they returned from a smoke break. She stated that she was not sure if a resident relationship would be something that they care planned because it was not necessarily part of their care. She stated typically the MDS nurse updated care plans and any nurse was able to update the care plan. She stated the Regional MDS Coordinator was responsible for care plans until they filled the MDS nurse position. In an interview on 05/06/25 at 2:35 PM with the Executive Director he stated that the MDS nurse was responsible for care plans and the Regional MDS Coordinator currently updated the care plans until the facility filled the MDS nurse position. He stated he was not sure if resident relationships would be care planned and was aware that Residents #4, #13, #22, and #28 were in relationships that were non-sexual. He stated care plans ensured staff knew what was going on with the resident and to ensure they addressed all their needs. In an interview on 05/09/25 at 12:53 PM with the Regional MDS Coordinator she stated it was important to care plan a resident relationship to ensure a resident's rights were respected, to guide a safety plan, and ensure the residents rights to privacy. She stated that care plans guide how they took care of residents. In an interview on 05/09/25 at 12:12 PM with the ADON revealed the MDS nurse was responsible for care plans and they were updated upon resident change of condition, during quarterly care plan meetings and the weekly standard of care meetings. She stated consensual resident relationships were important to care plan to ensure staff were aware of the relationship, the resident's consent status, and to know what level of privacy the residents were allowed. 7. Review of Resident #12's admission Minimum Data Set Assessment, dated 3/1/25, reflected she was a [AGE] year-old female with an admission date of 4/18/23. Resident #12 had no cognitive impairment, and her BIMS score was 15. She had upper and lower extremity impairment on one side and required use of a wheelchair. Resident #12 required assistance in putting shoes on, lower body dressing, bathing, toileting, and personal hygiene. Resident was also fully dependent in transfers and turning in bed. Resident had the following active diagnosis: Stroke (a medical condition that occurs when blood flow to the brain is interrupted or reduced, leading to brain cell damage) (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin), Arthritis (swelling or tenderness I one or more joints, causing joint pain or stiffness that often gets worse with age), Non-Alzheimer's Dementia (brain disorder that caused progressive cognitive decline), unspecified lack of coordination, unsteadiness on feet and muscle weakness. Review of Resident #12's Order Recap Report dated 5/8/25 reflected an order for 07/26/23 to 6/12/24 .may have brace to left hand to prevent contracture. Wear brace during day and off at night. Two times a day for Preventative . Review of facility Contracture Management Log for December 2024 reflected Resident #12 was evaluated on 11/27/24 and a contracture was observed on left hand that required a splint. Review of facility Contracture Management Log for April 2025 reflected Resident #12 was evaluated on 02/24/25 and a contracture was observed on left hand that required a splint. Observation of Resident #12 on 05/05/25 at 7:54pm revealed possible contracture on left hand without a brace or splint. The surveyor attempted to interview the resident but there was no response. Review of Resident #12's care plan revised 1/21/25 reflected .Resident Complains of Increased Pain / Discomfort and is at Risk for Injury from Decrease in ADLs Disease process Date Initiated: 01/21/2025 Revision on: 01/21/2025 o The resident will not have an interruption in normal activities due to pain through the review date. Date Initiated: 01/21/2025 Target Date: 01/14/2025 o The resident will not have discomfort related to side effects of analgesia through the review date. Date Initiated: 01/21/2025 Target Date: 01/14/2025 o The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Date Initiated: 01/21/2025 Target Date: 01/14/2025 o Administer analgesia tylenol as per orders. Give 1/2 hour before treatments or care. Date Initiated: 01/21/2025 Revision on: 01/21/2025 LPN RN o Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Date Initiated: 01/21/2025 CNA LPN RN o Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Date Initiated: 01/21/2025 Revision on: 01/21/2025 LPN RN o Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function. Date Initiated: 01/21/2025 LPN RN Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Date Initiated: 01/21/2025 LPN RN o Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. Date Initiated: 01/21/2025 LPN RN o Monitor/record/report to Nurse any s/sx of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Date Initiated: 01/21/2025 CNA LPN RN o Monitor/record/report to nurse loss of appetite, refusal to eat and weight loss . Resident #12's Care Plan did not reflect interventions for her left-hand contracture or for the use of a brace on the contracted hand. Interview with the Director of Rehabilitation on 05/07/25 at 1:14pm revealed Resident #12 had PT and OT from 2/24/25 to 4/18/25 and was discharged due to plateauing in her progress. Resident #12 had a contracture to her left hand and should have had a splint as there was an order on file, as he insured it was there. He stated Resident #12 was also on the Contracture Management Logs and was followed up with every quarter, last follow-up was 04/15/25. The Director of Rehab was unable to provide the active order, and stated someone had cancelled the order without discussing it with him. He would have never recommended the order be discontinued, as Resident #12 needed the splint to help manage her contracture. There should always be an order for the splint and the splint/brace should be care planned. They needed to have an order to obtain the appropriate consents. He stated he would assess Resident #12 immediately and enter the order. Interview with CNA X on 05/07/25 at 1:24pm revealed Resident #12 had a splint on her left hand at one time but wouldn't keep it on. CNA X had not had her put it on recently and had no idea where the split was at. The only thing being done for her contracture was Resident #12 used a stress ball. Observation of Resident #12 on 05/07/25 at 1:23pm revealed the resident sitting in the common area watching TV without a splint or brace on her left hand. Interview with CNA J on 05/08/25 8:42am revealed she was not familiar with the resident, as she had just started working the resident's hall but stated Resident #12 did not have a splint yesterday or this morning. The aide stated residents with a contracture would normally have a splint or brace and access to toys that would help with the contracture. Interview with LVN A on 05/08/25 at 9:16am revealed Resident #12 had a contracture and therapy had given the resident a splint, but she was unsure if it was an active order because she had not seen Resident #12 with it on. She stated that a care plan would have had the need for a splint for a contracture. The risk of not wearing the splint if it was recommended by therapy was the risk of the contracture getting worst and causing more pain. Interview with the Regional MDS Coordinator on 05/08/25 at 11:57pm revealed it was the job of the MDS coordinators to complete the comprehensive care plan. The nurses and Administration Team would update the care plans with new orders or acute orders. A splint or brace would be something that was listed on the care plan. She was unable to provide a care plan for Resident #12 that had the splint or brace listed as an intervention for contracture. The risk to the resident of not having the splint care planned would have been that everyone would not be aware of the resident's needs related to her contracture causing more issues for the resident. Interview with the Director of Nursing on 05/08/25 at 12:09pm revealed she was unsure if Resident #12 had a contracture. She stated that contractures and splints would have had orders and were care planned. She stated every intervention used on residents needed to be care planned, the risk of not having a splint in the care plan was that the hand could become more contracted. The MDS nurse should have kept care plans updated, but all nurses had the ability to update care plans. The Regional MDS Coordinator was filling in for the MDS nurse because the position was vacant. Interview with the Executive Director on 05/08/24 at 12:45pm revealed the MDS coordinator oversaw updating care plans but the DON, ADON and social worker could also update them. Care Plans should include splints or braces if needed. Anything that has an order should be care planned. The risk of not having a splint care planned would be that the resident wouldn't receive everything they needed. Interview with RN G on 05/08/25 2:30pm revealed she was aware that Resident #12 had a contracture on one and that she had received therapy multiple times. She reported Resident #12 had a brace for her contracted hand at one point and believed she still had it but no longer used it. She stated that Resident #12 didn't like to use it and it was discontinued in the orders a long time ago. She stated that contractures and braces were included in care Pplans. Interview with the Director of Rehabilitation on 05/08/27 at 2:57pm revealed that he no longer had access to Resident #12's OT evaluation that had the discharge recommendation for brace or splint because it was in their old electronic system and they switched over to a new system in April. He only had the OT discharge evaluation from 4/18/25 that did not list the brace for the contracture on it. He stated that he was sure Resident #12 required a splint/brace because he had put the order in and someone had discontinued it without discussing with him. He stated he reassessed the resident yesterday and she continued to have a contracture and needed a brace. He entered in the order for the brace. He stated Resident #12 continued to be listed on his Contracture Management log. He stated he always discussed the need of a split/brace with the IDT and would teach the nurses and CNAs how to put it on safely. the length of time to wear it, what to assess for in order to take it off and how many times per day it was necessary. He stated he did this when he entered the order and discharged the resident from therapy. Record review of the facility's policy, Comprehensive Care Plan revised on 04/25/21 reflected: .The Care Plan is revised every quarter, significant change of condition, Annual or as the resident condition changes on an individualized basis. The Care Plan process is an ongoing review process .5. The Interdisciplinary Team will review the healthcare practitioner's notes and orders (e.g. dietary needs, medications, routine treatment, etc ) and implement a Comprehensive Care Plan to meet the residents' care needs including but not limited to: .b. Physician orders .d. Therapy services .l. Psychosocial Mood State/Adjustment to Placement/PASRR Needs as indicated .

Based on observation, interview, and record review, the facility failed to protect the residents right to be free from abuse and neglect for one (Resident #4) of 10 residents reviewed for abuse and neglect. The facility failed to protect Resident #4 (female resident) right to feel safe when she told the facility that she did not feel safe sharing a room with Resident #13 ( male resident). Resident # 4 told the facility that she did not want to be in a room with Resident #13. Resident #4 no longer remembered her relationship with Resident #13. The facility failed to address Resident #4's concerns and allowed her to continue to reside in the same room as Resident # 4. An Immediate Jeopardy (IJ) was identified on 05/07/25. The IJ template was provided to the facility on [DATE] at 1:43 PM. While the Immediate Jeopardy was removed on 05/09/25, the facility remained out of compliance at a scope of pattern and a severity level of no harm that is not Immediate Jeopardy due to facility continuation of in-servicing and monitoring the plan of removal. This failure could place residents at risk for not having measures in place to protect them from serious harm and mental anguish. Findings included: Record review of Resident #4's Quarterly MDS, dated [DATE], reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. She had the diagnoses of dementia (loss of cognition), anxiety disorder (sudden feelings of intense worry), major depressive disorder (persistent feelings of sadness or loss of interest), bi-polar disorder (periodically intense emotional states), schizophrenia (mental health condition that affects how people think, feel and behave) and a BIMS score of 8 (moderately impaired cognition). Record review of Resident #4's care plans revised 11/17/23 revealed there was no care plan area for the resident's cohabitation and relationship with Resident #13. Further review reflected she had impaired cognitive function or thought process due to dementia, interventions included cue and reorient and supervise as needed, dated initiated 02/02/25. Further review revealed she identified as a trauma survivor with trauma category of: Serious illness, childhood trauma, neglect, psychological trauma, dated initiated 7/21/21, and interventions included ask for permission to enter resident's room . be conscious of resident position when in groups, activities, dining room to promote proper communication with others and feelings of safety .behavioral health consults as needed, psychiatrist or counselor . Record review of Resident #13's Comprehensive MDS, dated [DATE], reflected he was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE]. He had the diagnoses of dementia (loss of cognition), anxiety disorder (sudden feelings of intense worry), bi-polar disorder (periodic intense emotional states), psychotic disorder (episodes of disrupted thoughts and perceptions), and schizophrenia (mental health condition that affects how people think, feel and behave) and a BIMS score of 11 (moderately impaired cognition). Record review of Resident #13's care plan revised 10/23/23 revealed there was no care plan area for the resident's cohabitation and relationship with Resident #4. Further review reflected he had impaired cognitive function or impaired thought process due to confusion to time and a short-term memory deficit, dated initiated 09/20/18, interventions included engage in simple, structured activities, keep his routine constant, present just one thought, idea, question, or command at a time. Further review revealed he had a behavioral problem due to anxiety and had delusions including he believed he was a prisoner of war and yelled out to relieve stress, dated revised 12/19/21, interventions included .caregivers provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by, if reasonable, discuss behavior .explain/reinforce why behavior is inappropriate . Record review of Resident #4's census report revealed she moved in room [ROOM NUMBER] on 4/28/22. Record review of Resident #13's census report revealed he moved to room [ROOM NUMBER] on 01/19/23. Record review of Resident #4's progress notes reflected: Dated 04/14/25 at 6:45 AM by LVN A: .Resident stated to night shift staff, There's a man in my room! Staff attempted to redirect and inform her that he is her roommate and boyfriend [Resident #13]. Resident responded, I don't know him! Resident would not go back to her room. Resident repeatedly asked staff, How do I get out of here? Resident then sat on the couch, waiting for her ride. Resident stayed on the couch and slept. At this time, resident continuing to sleep on couch. Dated 04/14/25 at 9 AM by LVN A: Resident woke up @ 0830 (8:30am) on the couch and came to the nurse's station asking, How do I get out of here? Nurse redirected resident to her room. Resident remembered who her boyfriend was [Resident #13]. Resident came back to the nurse's station immediately after entering her room and again asked, How do I get out of here? Nurse redirected resident for a second time. Whenever resident would enter her room, she would immediately come back up to the hall to the nurse's station asking how to leave. Nurse able to redirect resident to eat breakfast. Notified DON, ADON, and MD. Resident placed on Q(every)15 min elopement monitoring. Dated 04/15/25 at 1:30 PM by LVN A: Resident has had no attempted elopement this shift. Resident did come to staff members multiple times this shift asking, How do I get out of here? Resident redirected successfully each time. Dated 04/16/25 at 12:35 PM by LVN A: Resident has had no attempted elopement this shift. Resident did come to staff members multiple times this shift asking, How do I get out of here? Resident redirected successfully each time. Resident has had continuous bouts of confusion and has had barely any appetite since being treated for UTI. N/O UA PCR to ensure that resident's UTI has fully been treated. Dated 04/16/25 at 6:28 PM by LVN A reflected the urine PCR was collected and Resident #4 did not have any signs or symptoms of distress. Dated 04/17/25 at 7:45 AM by LVN A: When delivering breakfast tray to resident, resident asked CNA, 'How far away will you be?' CNA explained that she was passing breakfast trays on the hall. Resident explained, 'That creepy man over there keeps staring at me and I just wanted to know where you will be if I need you.' Resident was referring to her boyfriend [Resident #13]. Resident has had persistent confusion past normal baseline. Pending UA PCR results for f/u on previous UTI. Resident continuing Q15 min monitoring for elopement. Dated 04/17/25 at 8:10 AM by LVN A: Resident and her boyfriend, another resident, were ambulating up the hallway and they stopped so her boyfriend could use the bathroom. When boyfriend came back, resident yelled out to nurse's station, Where did my boyfriend go? Boyfriend looked back at her and said, It's me! Resident then stated, No you're not my boyfriend! Nurse reoriented resident successfully. Dated 04/17/25 at 12:10 PM by the Director of Resident Support Services: .Resident has been experiencing increased confusion and has expressed a desire to leave the facility. Nursing staff have been consistently redirecting her during these episodes . Dated 04/17/25 at 1:27 PM by LVN A reflected Resident #4 was assessed by behavioral health services regarding increased confusion, 15 minute checks were discontinued and medications adjusted. Dated 04/23/25 at 12:09 PM by LVN A: Resident confused and does not remember her boyfriend. Resident refusing to sit with boyfriend at lunch. Dated 04/23/25 at 8:12 PM by LVN B: .Resident very confused today and could not remember boyfriend and refused to be left in the same room with him. Dated 04/23/25 at 11:23 PM by the ADON: Upon start of shift, this resident was up in dining area sitting in a chair alone. Previous shift reported that she did not want to go into the room with her boyfriend. This nurse went to speak to this resident and assisted her to her room. No issues with assisting resident to bed. This nurse spoke with resident's boyfriend/roommate and asked that he give her some time and explained that she is just confused right now. Boyfriend/roommate verbalized understanding . Dated 04/24/25 at 12:45 PM by LVN A: During lunch, resident refused to sit with her boyfriend/roommate. Resident stating he is not her boyfriend and that he is weird. Resident ate with another resident while her boyfriend/roommate ate at a different table. Resident continues to exhibit increased confusion. Resident unable to find her room or the dining room without assistance from staff. Dated 05/05/25 at 9:25 PM by LVN B: Resident was exit seeking earlier today so we implemented 15 minute checks at 9:30pm. Record review of Resident #4's Q15 elopement monitoring, start dated 04/14/25-04/17/25 reflected Resident #4 was monitored every 15 minutes. Record review of Resident #4 lab results revealed a UTI panel, dated collected 03/21/25 and reported 03/24/25, tested positive for Escherichia coli (bacteria). Further review revealed another UTI panel, dated collected 04/16/25 and reported 04/18/25, tested negative for Escherichia coli (bacteria) and positive for Staphyloccus spp (bacteria). Record review of Resident #4's physician's orders revealed the following orders: -Ciprofloxacin 500 mg, one tablet by mouth, for 10 days for a UTI, start dated 02/25/25 and end dated 04/04/25. -urine analysis PCR for follow up of previous UTI, dated 04/16/25. -Ciprofloxacin 500 mg, one tablet by mouth, for 7 days for a UTI, start dated 04/21/25 and end dated 04/28/25. In an interview and observation on 05/05/25 at 7:17 PM with Resident #4 and Resident #13 revealed she was sitting up in bed and stated she was doing well. Resident #13 entered the room and he stated that he lived with his girlfriend (Resident #4) and they were married. He stated to Resident #4 Tell her that we are married. Resident #4 looked at Resident #13 and did not reply. In an interview on 05/05/25 at 8:36 PM with MA S, she stated Resident #4 and Resident #13 were boyfriend and girlfriend and resided in the same room for years and the family was aware and they were happy together. She stated it was not a sexual relationship and had not seen the residents in the same bed for at least a year and especially with Resident #4's incontinence. She stated Resident #4 had dementia and recently had increased confusion of her surroundings and more frequent incontinence. She stated they were monitoring her frequently. In an interview on 05/06/25 at 9:14 AM with Resident #4, she stated she had a roommate who was male and she did not like it. She stated she had girlfriends and did not want a boyfriend because it made her feel uncomfortable because sometimes boyfriends were mean. She stated there was no physical or sexual contact between them, and she denied that Resident #13 harmed her in any way. She stated he liked to sit on her bed and look out the window. She stated she didn't like him and didn't want to spend time with him but was not sure why, when he was around her she felt pretty bad. She stated she felt safe at the facility. In an interview on 05/06/25 at 9:29 AM with Resident #4's responsible party revealed she had last seen Resident #4 about 2 months ago and spoke with her over the phone on 05/05/25 and was unaware that Resident #4 voiced any discomfort with her roommate, Resident #13. She stated that she spoke with staff about 10 days ago about Resident #4's advanced directives and there was no mention Resident #4 was uncomfortable with Resident #13. She stated Resident #4 had a cognitive decline in the last few months but she found it hard to believe that Resident #4 felt uncomfortable with Resident #13. In an interview on 05/06/25 at 11:48 AM with Resident #13 revealed he and Resident #4 broke up last week and they were just companions now and it was not a sexual relationship for at least a year. He stated he planned to discharge from the facility and had just purchased a helicopter. He stated he was a prisoner of war. In an interview on 05/06/25 at 10:16 AM with LVN A revealed Resident #4 and Resident #13 developed a friendship that developed into a relationship, and they eventually moved into the same room with the approval of both resident representatives. She stated Resident #4 recently had a cognitive decline and had two courses of antibiotics for a UTI and was frequently incontinent. She stated there were some days Resident #4 knew who Resident #13 was; and other days she did not know who he was. She stated that Resident #4 asked her why there was a random man in her room (Resident #13). She stated that Resident #4 would sit and waited for a ride in the lobby area and she was being monitored with 15 minute checks until the behavioral health services assessed her for a secure unit placement. She stated she remembered writing the progress notes and it was discussed in a morning meeting about possibly moving Resident #4 to a different room. She stated in the meeting it was determined if they moved her to a different room then Resident #13 would have still sought her out and if Resident #4 was placed on the secure unit, they would be able to ensure they were separated; Resident #4 had also displayed more exit seeking behaviors. She stated behavioral health services determined she was not at a high enough risk to be admitted to the secured unit and it had not been discussed again. She stated she did believe Resident #4 could have felt unsafe and Resident #13 was also upset that Resident #4 did not remember who he was. In an interview on 05/06/25 at 12:30 PM with the Director of Resident Support Services revealed Resident #4 had dementia, was confused and doesn't understand why she was at the facility, her last BIMS score was a 3 (severe cognitive impairment). She stated Resident #13 also had confusion and had a low BIMS score. She stated she spoke with Resident #4 on 05/05/25 and had not heard any concerns about Resident #13. She stated a resident who did not remember their significant other or started to call them creepy, refused to go into their room or refused to sit with each other at mealtimes was a cause of concern regarding consent and abuse and could cause a resident to physically lash out at the other roommate if they invaded their space. In an interview on 05/06/25 at 12:41 PM with the DON revealed Resident #4 had a significant change in her cognition a couple of weeks ago and was more confused, was not sure where she was and stated she wanted to leave, did not recognize nursing staff or Resident #13, they placed her on 15 minute checks and tested her for a UTI- it was positive and had to go through several rounds of antibiotics and had medications adjusted. She stated that she was not aware of the progress notes that used the words creepy or weird and only remembered they discussed Resident #4's general confusion. She stated if she had known she would be concerned with resident safety and would have intervened and temporarily moved her to ensure she felt safe, informed the Executive Director, and reevaluated any causes. She stated there was not an assessment for resident consent for relationships and there was not a policy regarding resident cohabitation or relationships and did not know if it would be something to be care planned. In an interview on 05/06/25 at 1:03 PM with the ADON revealed Resident #4 and Resident #13 had been roommates for years and it had been good for a while, they typically sat together for every meal. She stated that recently Resident #4 had a UTI and was confused about where she was and who Resident #13 was and she reoriented Resident #4 to her room and to Resident #13. She stated that there were times Resident #13 came to her and was concerned because Resident #4 did not recognize who he was and was refusing to go to their room, she told Resident #13 to give Resident #4 some time and explained Resident #4 was confused. She stated that in a morning meeting LVN A brought up possibly moving Residents #4 and #13 to a separate rooms but there were concerns that Resident #13 would go into whatever room they moved Resident #4 to. Interview revealed there was a discussion about possibly admitting Resident #4 to the secured unit . The ADON could not remember why a change was not made. In an interview on 05/06/25 at 2:35 PM with the Executive Director revealed he started working at the facility in April of 2024 and Resident #4 and Resident #14 were already established roommates and were alright, as far as he knew it was a companionship. He stated he knew that Resident #4 had confusion and did not know the details. He stated Resident #4's progress notes would be a cause for concern for possible abuse and if he had known then he would have involved the Director of Resident Support Services and at least temporarily separated the residents or offered to separate the resident. He stated that he expected staff to report concerns to him and for the DON to inform him during morning meeting of any concerns so that they know what was going on with residents and make sure the facility addressed all their needs. He stated the facility did not have a policy for resident capacity or consent or regarding resident relationships. He stated that consent concerns would be assessed as needed, when there were concerns from family or friends, or the resident then they reassessed the situation. In an interview on 05/06/25 at 2:59 PM with LVN B revealed she started working at the facility about 3 weeks ago, and staff told her Resident #4 and Resident #13 were boyfriend and girlfriend and roommates. She stated Resident #4 did not want to go into her room with Resident #13 and she told LVN B that she did not want to be in the same room as Resident #13 and that she did not know him. LVN B stated she took Resident #4 to an empty room and suggested she sleep there. She stated Resident #4 asked LVN B why would she not want to sleep in her room and LVN B replied that Resident #4 said she felt uncomfortable with her boyfriend (Resident #13). She stated she notified the oncoming shift and continued to check on Resident #4 every 15 minutes due to her elopement risk. She stated that Resident #4's comments were concerning because it showed she felt like he was a threat to her. She stated she was not aware of the progress note where Resident #4 called Resident #13 creepy and stated she would have questioned Resident #4 more on why she used the word creepy because it sounded like she felt frightened to be alone with him. In an interview on 05/06/25 at 4:49 PM with the Director of Rehabilitation revealed Resident #4 recently had a decrease in her cognition level due to a UTI and suddenly started to dislike her roommate (Resident #13) and did not recognize him. He stated that about a week ago Resident #4's wandering, confusion, and not remembering Resident #13 was brought up during a morning meeting with the department heads. He stated he suggested they move Resident #4 to another room due to dementia and the male-female dynamic and was not sure why the residents were not moved. He stated that he could not remember if the Executive Director was present at the time. In an interview on 05/08/25 at 11:55 AM with CNA H (worked all shifts) revealed Resident #4 started to not recognize Resident #13 around January 2025 and then more consistently in the past month. CNA H stated Resident #4 said things like there's a strange or weird man in her room and she didn't know who he was. She stated she took her to LVN A who reoriented Resident #4 to Resident #13 and told her that's your boyfriend- you live with him. CNA H stated sometimes Resident #4 remembered who Resident #13 was and other times she would say no, I don't know him and went to the lobby and stayed there about an hour or so then came back and did the same thing again. CNA H stated staff redirected Resident #4 with coffee, snacks, activities, smoking breaks and eventually Resident #4 went back to her own room. She stated Resident #4 did seem afraid and confused and she saw now that it could have been a sign of abuse. Record review of the facility's freedom from abuse and neglect policy, titled Abuse, dated effective 02/01/17 and revised 0/01/23, reflected: .each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement, and or Misappropriation of property. The facility staff will adhere to the policies and procedures and will follow the guidelines in the written policy and procedure. The facility administrator is the appointed Abuse Coordinator, and in his/her absence a designee will be appointed. Abuse is a willful infliction of injury or negligent, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct that would constitute an offense under penal code S 21.08 (indecent exposure) or Penal code chapter 22 (assaultive offenses), sexual harassment, sexual coercion, or sexual assault. Residents will not be subjected to abuse by anyone, including, but not limited to community staff, other residents . .Reporting/Investigation: The law requires the abuse coordinator/designee, or employee of the facility who believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect or exploitation caused by another person to report the abuse, neglect or exploitation . Investigations will focus on determining if the abuse occurred, the extent of the abuse, and potential cause(s) . The abuse coordinator with the Director of Nursing/ designee will investigate all allegations and use the appropriate forms to document the investigation and turn it in to HHS within 5 calendar days. Upon completion of an investigation, the Director of Nursing and Administrator will analyze the occurrences, and determine what changes, if any, are needed to prevent further occurrence. All documentation of investigation must be protected and made available upon request. Protection: It is utmost important that resident(s) suspected of being abused, and all other residents must be protected during the initial identification, and investigation process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm . In the event of resident-to-resident abuse, the facility will immediately protect the resident being abused and all other residents in the facility. If the initial determination is that the perpetrator is a threat to the health and safety of the residents in the facility, as determined by the attending physician/or other physician, the resident will be discharged as soon as possible. During the time that the perpetrator has not been discharged , the facility will monitor this resident one-on-one to protect all other residents. The Director of Nursing will coordinate this and set up monitoring. If a threat does not exist then an assessment will be completed, and behavior will be care planned to meet resident's needs and protect others. Record review of the inservice record dated 04/21/25 revealed the facility inserviced staff on the Long Term Care Regulation Provider Letter with emphasis on the timeliness of reporting. Review of the Long-Term Care Regulation Provider Letter, PL 2024-14 issued August 29, 2024 revealed .HHSC rules define neglect as the failure to prvide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain or mental illness. CMS defines neglect as the failure of the facility, it's employees or service providers tor provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . An Immediate Jeopardy was identified on 05/07/25. The Administrator and DON were notified on 05/07/25 at 1:43 PM of the Immediate Jeopardy. The IJ template was provided at this time and plan of removal was requested. The facility's plan of removal was accepted on 05/08/25 at 6:26 PM. The accepted plan of removal for the Immediate Jeopardy included the following: The following is a plan of?removal, which has been immediately?implemented?at [the facility], to remedy the immediate jeopardy as a result of alleged deficient practices, which?was imposed on May 7, 2025 at 1:55pm.? On 5/7/2025 at 10am [Resident #4] was removed from the same room and placed on a separate unit away Resident #13. Resident #4 placed on enhanced supervision on 5.5.25. Resident #13 was placed on enhanced supervision 5.6.25. Resident #4 and Resident #13 assessed for signs/symptoms of abuse/neglect, physical or mental, harm by Regional Director of Clinical Services. No negative findings identified. Psych service vendor contacted by Social Services and [DON] 5.7.25 to conduct off cycle visit on 5.8.25 and/or medication review for resident #4 and resident #13 who are currently already on services with this provider per physician orders. Medical Director contacted by facility on 5.7.25 to conduct on-site assessment for Resident #4 and Resident #13 on 5.8.25. On 5.7.2025 [Executive Director], [DON], [ADON], received one to one education from Regional Director of Clinical Services on abuse/neglect/exploitation/identifying and reporting, adhering and following policy and procedures, and complying with State and Federal Guidelines. [Executive Director], [DON], and [ADON] will be in-serviced on resident to resident relationships upon the development of the policy and procedure on 5.8.25, On 5.7.25 [the facility] contacted the legal team to assist with the development of a policy and procedure for resident to resident relationships. Completion date for the development and adoption of such policy and procedure will be 5.8.25. All staff will be staff in-serviced on Resident to Resident relationships on May 8, 2025 by [Executive Director/DON], and/or designee. In-service education included but not limited to, who to report suspected relationships to, facility obligations to serve residents participating in a resident to resident relationships, resident capacity and consent for relationships, and facility response when a potential relationship is identified. Facility will communicate changes in resident relationship statuses during routine morning meetings with the IDT team and clinical staff members. All staff not present at time of in-service will not be permitted back to work until in-service is complete. All staff in-serviced on abuse, neglect, and exploitation on May 7, 2025 by [Executive Director] and [DON]. All staff not present at time of in-service will not be permitted back to work until in-service and competency test is complete. Completion date 5.8.25. LVN A, LVN B, ADON, DOR and DON received one to one in-service for resident to resident relationships and abuse/neglect/exploitation identifying and reporting on 5.7.25 by Regional Director of Clinical Services. All residents with the ability to communicate interviewed by [Director of Resident Support Services] and/or designee on 5/7/2025 for potential safety concerns. Nonverbal residents assessed on 5.7.25 for signs and symptoms of abuse/neglect/exploitation. The Medical Director was initially made aware May 7, 2025 of the immediate jeopardy, and has?been involved?in the development of the plan to remove during an abbreviated QA (Quality Assurance).These conversations are considered a part of the QA process. All in-servicing began 5/7/2025. No staff will be permitted to work until in-serviced. Completion date for all in-servicing will be May 8, 2025. This plan was initially implemented 5/7/2025 and will be monitored, through personal observation,?through completion byRegional [NAME] President of Operation, Regional Director of Clinical Services. Monitoring included: Record review of facility's resident relationship policy titled Consensual Intimate Relationships Between Residents, undated, reflected: Purpose: To establish guidelines and procedures regarding consensual intimate relationships between residents in the skilled nursing facility while ensuring the safety, dignity, and rights of all residents. Policy Statement: The facility recognizes and respects the personal rights of residents to engage in consensual intimate relationships with one another. This policy aims to provide a framework for supporting such relationships while maintaining a safe and respectful environment for all residents. Definitions: Consensual Intimate Relationship: A mutual relationship between residents that includes emotional, romantic, or sexual components, characterized by the voluntary agreement of both parties. Nonconsensual Intimate Relationship/Sexual Contact: If a resident appears to want the intimate relationship/sexual contact to occur, but lacks the cognitive ability to consent; or Does not want the intimate relationship/sexual contact to occur. Procedures: Residents will be informed of their rights regarding intimate relationships and the facility's policies. Both parties must be capable of providing informed consent, free from coercion or undue influence. Staff should assess the cognitive and emotional capacity of both residents to ensure they understand the nature of the relationship. Assessment of cognitive and emotional capacity will be assessed by either a licensed nurse, licensed social worker or psychiatrist/psychologist and will occur when a resident indicates a desire to engage in an intimate relationship or exhibits behaviors of engaging in an intimate relationship. Re-assessment of a resident's cognitive and emotional capacity who wish to continue in an intimate relationship will occur as needed or on certain changes of condition such as stroke, dementia, depression/psychiatric illnesses, illness, or other impacts such as medication(s), hearing/visual loss, and stress. Documentation of informed consent and assessment will be in the resident's electronic health record. Residents engaging in intimate relationships will be provided with adequate privacy. Staff will facilitate private spaces for such interactions, respecting residents' dignity and confidentiality. Staff will document any significant developments in the relationship, including any concerns raised by residents, family members, or staff and will intervene when appropriate to ensure the safety of residents. Monitoring included: Record review of an in-service, dated 05/07/25, reflected staff on all shifts were in-serviced on identifying abuse and neglect and reporting requirements, signed by nursing staff including the DON, ADON, LVN A, LVN B, occupational/speech/physical therapy staff and the DOR, Director of Resident Support Services, Director of Life Enrichment, housekeeping staff and the Director of Environmental Services. Record review of an in-service, dated 05/07/25, reflected an in-service on identifying and reporting abuse and neglect and resident to resident relationships was signed by the Executive Director, DON, ADON, DOR, LVN A and LVN B. Record review of an in-service dated 05/08/25, reflected staff on all shifts were in-serviced on the consensual intimate relationships policy was signed by nursing staff including the DON, ADON, occupational/speech/physical therapy staff, dietary staff, Director of Resident Support Services, Director of Life E[TRUNCATED]

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure adequate supervision and put measures in place to prevent Resident #1 who was at risk for eloping from the facility. Resident #1 had history of confusion, exit seeking behavior and wandering behavior. On 12/20/24, Resident #1 eloped out of the facility and the facility was not aware the resident eloped. Resident #1 was walking the streets about 3 blocks away from the facility in a residential area. The noncompliance was identified as PNC. The IJ began on 12/20/24 and ended on 12/26/24. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of potential accidents, injuries, harm or death. Findings include: Review of Resident #1's face sheet undated reflected Resident #1 was admitted to the facility on [DATE] from another skilled nursing facility with diagnoses of Muscle Wasting and Atrophy (significant shortening of the muscle fibers and loss of overall muscle mass), Syncope and Collapse (fainting), Dementia (loss of cognitive functioning that interferes with daily life and activities), Depression, Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), Glaucoma (eye disease that can cause vison loss and blindness and blindness), Hypertension, Osteoarthritis (chronic degenerative joint disease), Generalized Muscle Disease, Unsteadiness on feet, lack of coordination and cognitive communication deficit. Resident #1 was not her own responsible party. Review of Resident #1's Admission MDS dated [DATE] reflected Resident #1 had a BIMS of 7 indicating she was severely cognitively impaired. Resident #1 had wandering behavior daily. Resident #1 was independent with ambulation with no assistive devices. Resident #1 required supervision with ADLs except she required partial/moderate assistance with bathing. Review of Resident #1's Admitting paperwork from previous facility discharge summary reflected: [Resident #1] has cognitive impairments and requires redirection for orientation, care and safety. [RP] would like to secure placement in a long-term care facility that can assist with redirection for wandering/exit seeking and a secure unit as needed. Review of Resident #1's baseline care plan dated 12/06/24 reflected Resident #1 was an elopement risk. Resident #1 was cognitively impaired due to forgetfulness and dementia. Review of Resident #1's Comprehensive Care Plan dated 12/20/24 reflected the following: -dated 12/20/24 Resident #1 had impaired cognitive function or impaired thought processes related to impaired decision making abilities, is not always understand or able to understand verbal and non-verbal expression related to dementia. -revised 12/31/24 Resident #1 is an elopement risk/wanderer and is at risk for possible injury [related to] impaired safety awareness and diagnosis of dementia 12/20/24 Resident had elopement event. Interventions included Distract resident from wandering ., Provide structured activities ., secure unit placement for increased monitoring. -revised 02/06/25 Resident #1 resides on the facility security unit [due to] wander/elopement risks related to history of attempts to leave facility unattended, impaired safety awareness, resident wanders aimlessly. Interventions included Identify pattern of wandering: Is wandering purposeful, aimless or escapist? .Intervene as appropriate. Review of Resident #1's Incident Report dated 12/20/24 reflected elopement incident for Resident #1. It reflected received phone call that resident was at a nearby house. Resident of the home was able to retrieve this resident's cell phone and call resident's[RP]. [RP] picked resident up and returned resident to facility. Resident states 'the girls and I went to a dance and got lost. Head to toe assessment performed, with no injuries noted. Resident on one-on-one monitoring until moved to secure unit on this day .Admin initiated self-report. Medical Director informed. Resident #1 was oriented to person only. Resident #1 had predisposing physiological factor s of confused and impaired memory. Review of Resident #1's 24 Hour report dated 12/20/24 reflected Resident #1 elopement 12/20/24. One to one monitoring until moved to unit moved to 509B. Observation and Interview on 03/12/25 at 10:28 AM revealed Resident #1 was sitting on her bed in her room on the secure unit. Resident #1 was confused and could not recall the incident. She stated she felt safe at the facility. Review of Resident #1's progress note for December 2024 reflected the following: Dated 12/05/24 12:45 PM by RN A resident admitted to facility ambulatory has dx of dementia and wondering alzheimers .very pleasant oriented to room .will continue to monitor and assess will update [medical doctor] family and admin prn status changes. Dated 12/06/24 12:40 PM by LVN B Resident exit seeking and attempting to exit out of 200 hall exit door. Resident redirected to eat lunch. Dated 12/06/24 1:55 PM by LVN B Resident continuing to attempt to exit seek. Resident pushing on exit doors. Staff attempting to redirect resident. Resident confused. [Alert and Oriented] x1. DON notified. Review of Incident/Accident Reports December 2024 to March 2025 reflected no other elopement incidents for any other residents in the facility. Interview on 03/12/24 at 1:54 PM with LVN C revealed Resident #1 eloped on 12/20/24 but he was not working when the incident occurred. He stated Resident #1 was confused, had wandering behavior and would ask about leaving the facility. He stated he had been in-serviced after the incident in December 2024 on elopement policy, signs/symptoms of residents at risk for elopement. He was knowledgeable about his role as a charge nurse for a missing resident. He stated Resident #1 was placed on the secure unit after the elopement incident. Interview on 03/12/24 at 3:22 PM with LVN B revealed Resident #1 had expressed desire to go home constantly, would say her family member was coming to pick her up, and asked LVN B what door do I exit from. She stated she would redirect Resident #1 when she expressed wanting to leave and go home. She stated on the morning of 12/20/24 before the incident Resident #1 was confused and did not understand why she was at facility. She stated Resident #1 required redirection and distraction from wanting to leave. She stated on 12/06/24 Resident #1 did have 2 occurrences of exit seeking on pushing on hall 200 doors and she documented it in the nurse's note. She stated she redirected Resident #1 when she attempted to exit seek and distracted her. She stated she was not aware of Resident #1's history if she was an elopement risk upon admission. She stated on 12/06/24 she was not Resident #1's charge nurse and could not recall who she notified about the exit seeking behavior for Resident #1. She stated she was in-serviced after the incident in December 2024 on elopement policy, signs/symptoms of residents at risk for elopement and completing elopement assessment. She was knowledgeable about her role as a charge nurse for a missing resident. She was unaware of any elopement incidents since Resident #1's elopement on 12/20/24. Follow-up Interview on 03/13/25 at 10:15 AM with LVN B revealed on 12/20/24 Resident #1 was last seen at the facility's Christmas party at 1:45 PM or 2 PM. She stated 2:00 PM is shift change so she was not working when Resident #1 returned to the facility after the elopement. She stated she documented Resident #1's exit seeking behavior on 12/06/24 in a nurse's note since she was not Resident #1's charge nurse. Interview on 03/12/24 at 3:40 PM with MDS Coordinator revealed Resident #1 admitted from another skilled nursing facility. She stated Resident #1 did have wandering behavior and the baseline care plan reflected she was at risk for elopement. She could not find an elopement assessment upon admission for Resident #1. She stated she was not working the day of Resident #1's elopement. She stated the charge nurse who admits a resident was responsible to ensure elopement assessment completed to determine resident's elopement risk level. She stated she was in-serviced after the incident in December 2024 on elopement policy and signs/symptoms of residents at risk for elopement. Interview on 03/13/24 at 8:45 AM with RN A revealed Resident #1 was oriented to her self only but confused about the place. Resident #1 was ambulatory and wandered within the facility. She stated Resident #1 would go to the door but was not aware of her attempting to exit prior to the elopement. She stated Resident #1 was a risk for elopement due to confusion and wandering behavior. She stated she was the admitting nurse for Resident #1 and she could not recall why elopement assessment was not done at admission. She stated she could not recall reviewing Resident #1's discharge paperwork from the previous facility. She was not aware Resident #1 was an elopement risk. She stated she was not aware Resident #1's baseline care plan showed Resident #1 as an elopement risk. She stated the DON was the charge nurse at time of elopement incident for Resident #1. She stated she was in-serviced after the incident in December 2024 on elopement policy, signs/symptoms of residents at risk for elopement. She stated after being in-serviced she was aware all residents upon admission should have elopement assessment completed to determine elopement risk. Interview on 03/13/25 at 9:25 AM with CNA D revealed Resident #1 was confused and would misplace her phone asking for assistance from facility staff to find it. She stated Resident #1 had occasional exit seeking behavior of going towards the exit doors. She stated Resident #1 constantly wandered within the facility and would ask to go to go with Resident #1's RP. She stated nurses were aware of Resident #1's wandering, confusion and exit seeking behavior. She stated Resident #1 was placed on the secure unit after the elopement incident. Interview on 03/13/25 at 9:32 AM with Med Aide E revealed she did could not recall Resident #1 prior to being on the secure unit and did not recall elopement incident for Resident #1 in December 2024. She stated Resident #1 was currently on the secure unit for resident safety. She stated she had been in-serviced on elopement policy and signs/symptoms of residents at risk for elopement. Interview on 03/13/25 at 9:55 AM with Resident #1's RP revealed at the previous facility she exhibited behavior of wandering and would go to the exit doors to look out. She stated Resident #1 was confused and had dementia. She stated Resident #1 had not eloped at previous facility but they had Resident #1 moved to this facility for the resident safety and risk for elopement. She stated she had not had a care plan meeting with the facility. She stated nursing had not reached out to her prior to this incident of any exit seeking behavior for Resident #1. She stated she did not meet with facility staff to review the baseline care plan and facility had not discussed with her secure unit until after this elopement incident. She stated on 12/20/24 when she was shopping at a local store she received a phone call from a stranger using Resident#1's phone informing Resident #1 was walking the streets in a residential area. She stated she responded by telling the stranger the resident could not be there she was a resident at the facility. She stated she immediately left to go get Resident #1. She attempted to call the facility and was not able to get through but called a friend who called the facility to inform them Resident #1 was found walking the streets. She stated when she got to Resident #1 it was about like 10 minutes from when she first received the phone call. She stated she found her about 3 blocks away from the facility in a black sweatshirt with pants, socks and shoes on. Resident #1 told her she was dancing with her friends and got lost. She stated Resident #1 was cold and shivering with a blanket covering her provided by the bystander. She stated the bystander told her Resident #1 had flagged them down on the street saying she knew them and was walking the streets in residential area. She stated the facility had informed her later she must have gone out the door after the Christmas party when other visitors were exiting. She stated she took Resident #1 back to the facility in her car and nurse assessed her. She stated Resident #1 was not injured and was mad when Resident #1's RP left. She stated Resident #1 was placed on the secure unit after the elopement incident. Interview on 03/13/25 at 10:29 AM with CNA F revealed she saw Resident #1 at the facility's Christmas party eating but she had to leave about 2 pm to transport another resident to an appointment. She stated Resident #1 did have exit seeking behavior and would express her desire to leave the facility especially after her family would visit. She stated she had been in-serviced after Resident #1's elopement on elopement policy, signs/symptoms of residents at risk for elopement, abuse/neglect. Interview on 03/13/25 at 10:48 AM with Activity Director revealed on 12/20/24 facility had a Christmas party in the dining room including facility staff, residents and visitors from 1:30 PM to 2:00 PM. She stated she saw Resident #1 at the Christmas party but she did not recall seeing her after that. She stated she was not at the facility when Resident #1 returned to facility after elopement incident later that day. She stated Resident #1 was ambulatory on her own, had some confusion and looked like a visitor. She stated she was not aware of Resident #1 exit seeking behavior. She stated there was like 60 people at the Christmas party and maybe she had followed visitors out the door after the party. Interview on 03/13/25 at 10:35 AM with CNA K revealed she was knowledgeable on elopement policy, signs of residents with elopement risk, abuse/neglect and would immediately report to Charge Nurse, Administrator and DON if a resident was found missing. She had been recently in-serviced on elopement protocol and abuse/neglect policy. Interviews on 03/12/25 at 1:21 PM and 03/13/25 at 11:45 AM with CNA G revealed she had been recently in-serviced on elopement policy and signs of residents with elopement risk. She was aware she needed to notify Charge Nurse, Administrator and DON when resident is found missing. She was knowledgeable of types of abuse/neglect and had been in-serviced on abuse/neglect recently. Interview on 03/13/25 at 11:28 AM with ADON revealed she was working today as a charge nurse and works the floor as needed as the charge nurse. She stated she was in-serviced on elopement protocol including signs of residents at risk for elopement and the nurse's role when resident is found missing. She stated she had been in-serviced on nurse responsibility to complete elopement assessment upon admission and as needed when resident exhibits exit seeking behavior. She stated when Resident #1 eloped she was at risk of injury. Interviews on 03/13/25 at 12:10 PM with LVN L revealed she worked 2 pm to 10 pm shift on 12/20/24 but was not the charge nurse for Resident #1. She stated she was unaware of resident elopement risk and had not witnessed any exit seeking behavior from Resident #1. She stated Resident #1 was ambulatory on her own and did look like a visitor. She stated Resident #1 had confusion. She stated she was in-serviced after the incident in December 2024 on elopement policy, signs/symptoms of residents at risk for elopement and completing elopement assessment. She was knowledgeable about her role as a charge nurse for a missing resident. Interview on 03/13/25 at 1:13 PM with DON revealed she was unable to provide any witness statements of Resident #1's elopement. She stated she was the charge nurse for Resident #1 on 2 pm to 10 pm shift on 12/20/24. She received a phone call from a friend to Resident #1's RP who also worked for the facility that Resident #1's RP had received a phone call from a stranger that Resident #1 was found at a neighboring house. The DON looked at incident report and stated she had received the phone call at 3:45 PM on 12/20/24 because this is when she initiated the incident report for Resident #1. She stated Resident #1's RP brought Resident #1 back to the facility and Resident #1 was confused saying she went dancing with her friends. She stated she assessed Resident #1 head to toe with no injury noted. She could not recall the specific vitals but stated Resident #1's vitals were within normal limits. She stated facility initiated 1:1 for resident safety when she returned and after consent placed her on the secure unit for exit seeking behavior and elopement incident. She stated when interviewing staff after the elopement Resident #1 was last seen by staff at Christmas party on 12/20/24. She stated Resident #1 did wander within the facility but she was not aware of any exit seeking behavior. She stated when she reviewed Resident #1's progress notes she found the note on 12/06/24 stating Resident #1 had exit seeking behavior and stated she was not made aware of it. She stated she completed the baseline care plan for Resident #1 and stated she put down Resident #1 was an elopement risk based on previous stay at skilled nursing facility. She stated she did not review the baseline care plan with Resident #1's RP and did not look to see if elopement assessment had been completed upon admission. She stated she completed Resident #1's elopement assessment after the incident on 12/20/24 indicating she was high elopement risk due to elopement. She could not recall discussing secure unit placement with Resident #1's RP until after she had eloped on 12/20/24. She stated nursing had been in-serviced on completing elopement assessments upon admission and as needed when residents exhibit exit-seeking behavior. She stated if she had been made aware of Resident #1's exit seeking behavior on 12/06/25 she stated an elopement assessment would have been completed to determine elopement risk and to discuss with team about secure unit placement for safety. She stated the potential risk of elopement was serious injury or accident for Resident #1. She stated Resident #1 had intermittent cognition especially after Resident #1's RP visited and did not understand why she was placed at facility. Interview on 03/13/25 at 1:55 PM with Administrator revealed Resident #1's Previous Facility expressed she would go to the exit door asking about a car. He was not aware of Resident #1 having exit seeking behavior until after elopement incident in December 2024. He stated facility investigation revealed Resident #1 was last seen at the Christmas party on 12/20/24 and may have exited behind visitors or other people at the end of the party. He stated Resident #1 did elope and was immediately placed on 1:1 with staff until placed on secure unit for elopement and resident safety. He stated there have been no other elopements. He stated if he was aware of the exit seeking behavior prior to incident they could have assessed her with elopement assessed and review to determine if she required more supervision. He stated the potential risk to Resident #1 could be injury and serious harm. He stated the facility completed an elopement drill with facility staff to ensure staff were knowledgeable of facility policy on elopement. Review of staff In-services reflected: 12/20/24 and 12/26/24 staff in-serviced on elopement education including elopement drill 12/26/24 nurses in-serviced on completing all admission assessments by DON included RN A, LVN B, LVN C, ADON, MDS Coordinator and other nurses. 12/20/24 and 12/28/24 staff in-serviced on abuse/neglect Review of facility's policy Elopement dated 11/01/19 reflected To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing .6. When the patient/resident is located, the nurse completes a head-to-toe assessment. The social service designee assesses the patient/resident for emotional distress. Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. Examples of criteria that put a resident at higher risk of elopement .Cognitive impairment (example: those who dementia, Alzheimer's, brain injury) Exit-seeking behaviors (example: confused resident that thinks he/she needs to go pick their kids up from the school) New admission wanting desperately to leave .History of elopement at other communities Review of facility's policy Elopement Risk assessment dated [DATE] reflected facility will assess all patients/residents for elopement potential in order to provide a safe and comfortable living environment. PROCEDURE 1. All patients/residents are assessed on admission by a licensed nurse for elopement risk utilizing the elopement risk assessment form. 2. All patients/residents are re-assessed for elopement potential by the licensed nurse/social service designee quarterly throughout a patient's/resident's stay and with a significant change .4. The licensed nurse or social service designee completes the elopement risk assessment form and presents to the interdisciplinary team for further intervention.6. The physician and the patient/resident or the patient's/resident's representative are notified of the patient's/resident's risk for elopement and the interventions that are recommended for prevention of elopement and patient/resident safety. 7. The patient's/resident's legal representative should be contacted, if possible, to obtain all pertinent information in relation to elopement risk .10. A licensed nurse documents in the nurse's notes and behavior monitoring flow record any exit seeking behavior on an on-going basis and interventions are adjust as needed. 11. A baseline plan of care should be completed on admission and any elopement risks should be identified. The DON and Administrator were notified and provided the IJ template on 03/13/25 at 6:05 PM of PNC IJ for F689. The DON was provided the IJ template for PNC F689 on 03/13/25 at 6:05 PM. The IJ began on 12/20/24 and ended on 12/26/24. The facility had corrected the noncompliance before the survey began

Based on observation, interview and record review the facility failed to identify and provide needed care and services in accordance with professional standards of practice, (Resident #1) of ten residents reviewed for quality of care. The facility failed to recognize when Resident #1 had a significant change in condition to his skin, by conducting accurate skin assessments ([DATE]), and providing showers to resident ([DATE]). Resident #1 went to an outside doctor appointment on [DATE] at 10:15am and was sent from this appointment to the emergency room where he was diagnosed with [CONDITION(S)] (bacterial infection), gangrene (death of tissue) and [CONDITION(S)] ([CONDITION(S)]-resistant staphylococcus aureus) of the right great toe. Resident #1 had to have his toe amputated on [DATE]. An Immediate Jeopardy was identified on [DATE] at 1:12 p.m While the IJ was removed on [DATE] at 3:00 p.m., the facility remained out of compliance at the scope and severity of actual harm and isolated. The facility was continuing to educate staff and was monitoring the effectiveness of the Plan of Removal. This failure placed residents at risk for delays in treatments and care which could result in clinical complications, further loss of limbs and/or death. Findings included: Review of Resident #1's admission record, dated [DATE], reflected he was [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with malignant Neoplasm of Colon (cancer in colon), Essential Hypertension (high blood pressure), Anxiety Disorder, and Urinary Tract Infection. Resident #1's MDS assessment, dated [DATE], reflected a BIMS (Brief Interview for Mental Status) score of 11 which indicated his cognition was moderate impaired cognition. Resident #1 required extensive assistance by one person physical help for bed mobility, dressing personal hygiene, toilet use, and locomotion on unit. He required limited assistance by one person for transferring to wheelchair. Resident #1's MDS reflected he was at risk for developing pressure ulcers/injuries but there were no unhealed areas noted. Resident #1's Progress Notes dated [DATE] reflected Transport set up via [transport company]. Pick up set for 9:45a on [DATE] for a 10:15 appt w/dr . Further review of prior progress notes revealed no concerns, complaints or issues with Resident #1's skin condition. Resident #1's Progress Notes dated [DATE] at 10:41am reflected res out to appt with Dr at 9:45AM via transport. Medlist sent Resident #1's Progress Notes dated [DATE] at 10:24 reflected resident in hospital Review of Resident #1's Weekly Skin assessment dated [DATE] at 05:33, signed and locked on [DATE] at 12:35 reflected Resident #1 allowed the weekly skin assessment to be completed.G. Are the residents nails clean and at a safe/appropriate length? Yes is marked. No other bruises, skin tears, abrasions, lacerations, rashes, moisture associate skin damage, pressure, venous, arterial, diabetic or surgical wounds were noted. Review of Resident #1's Weekly Skin assessment dated [DATE] at 05:33, signed and locked on [DATE] at 13:41 reflected Resident #1 allowed the weekly skin assessment to be completed.G. Are the residents nails clean and at a safe/appropriate length? Yes is marked. No other bruises, skin tears, abrasions, lacerations, rashes, moisture associate skin damage, pressure, venous, arterial, diabetic or surgical wounds were noted. Review of Resident #1's ADL-Bathing Task sheet for [DATE] to [DATE] reflected Resident #1 required Physical help in part of bathing activity with one person physical help. There was one check mark dated [DATE] at 21:59. There was no other documentation of baths given. Review of Resident #1's ADL-Dressing Task sheet for [DATE] to [DATE] reflected Resident #1 required Limited Assistance to Extensive Assistance by one person for dressing. Review of Resident #1's NP visit note dated [DATE] revealed Podiatry: [NAME] Ankle pain. Admits Burning. Admits Foot numbness. Admits Foot pain Review of Pressure Skin/Wound QI Log for all of [DATE] up to [DATE] provided by the DCO on [DATE], revealed no treatments or skin concerns for Resident #1. Review of Resident #1's Braden Scale for Predicting Pressure Score Risks dated [DATE], [DATE], and [DATE] and all noted to be at risk. Review of Resident #1's care plan dated [DATE] revealed Focus [Resident #1] has limited physical mobility r/t [related to] .Goal The resident will demonstrate the appropriate use of w/c [wheelchair] to increase mobility through the review date .Interventions .Monitori/document/report PRN [as needed] and s/sx [signs or symptoms] of immobility: contractures forming or worsening, thrombus formation, skin-breakdown Review of Progress Notes from Internal Medicine Physician dated [DATE] revealed Reason for Appointment: 1. F/u post surgery. Past Medical History: Right ankle [CONDITION(S)] with positive metastatic lymph node in groin ,d+[DATE] ., General Examination: GEN: Patient is much less talkative today than his usual self. He has lost quite a bit of weight since I last saw him. He sits in his wheelchair slightly disheveled. He is wearing how [sic] with socks .EXTREMITIES: no clubbing, cyanosis or [CONDITION(S)], up on removal of right now [sic] shoe, the patient's sock is bloodied . I removed the sock and noted that his right large toe has bloody ulceration involving the entire toe. It is painful upon palpation. Once disturbed the area bleeds freely .Assessments: 1. Ulcer of toe of right foot, unspecified ulcer stage .2. [CONDITION(S)] of unspecified part of limb .Treatment 1. Ulcer of toe of right foot, unspecified ulcer stage Notes: Patient/family advised to go to . ER for evaluation and admission for right great toe infection/cellitis [sic]. Ultimately admit for IV abx, wound care, and eventual placement in SNF for attempts at getting patient to be more mobile to be able to return back home Review of Resident #1's Hospital Records for Resident #1 dated [DATE] revealed .History of present illness: Chief complaint: Right great to and foot [CONDITION(S)] .Plan: admitted to Med Surg .Continue IV [MEDICATION(S)], wound culture, wound care, Podiatry follow up, may require amputation Review of Resident #1's Hospital Records for Resident #1, a picture dated [DATE] at 00:28 revealed Resident #1's right great toe noted to be red, swollen inflamed, with a black area in the middle of the toe where the toenail should be. The skin is scaly and appears dry with some scabbed areas. Review of Resident #1's Hospital Records for Resident #1, a picture dated [DATE] at 00:25 revealed Resident #1's lower back with a small pink, open area to his lower back, above his coccyx. It measured 0.5cm by 0.2cm Review of Resident #1's Hospital Records for Resident #1 dated [DATE] revealed .Right foot [CONDITION(S)] is better. Right great toe is swollen and has mild drainage. Wound culture grew [CONDITION(S)] and patient is currently on [MEDICATION(S)] Review of Resident #1's Hospital Records for Resident #1 dated [DATE] revealed .Right great toe looks infected with serosanguineous drainage. Wound culture grew [CONDITION(S)] and patient is currently on [MEDICATION(S)] .Anticipating right great amputation tomorrow Review of Resident #1's Hospital Records for Resident #1 dated [DATE] revealed . (Resident #1) is a [AGE] year-old male with [CONDITION(S)] who presents with what appears to be wet gangrene of the right great toe with underlying [CONDITION(S)]. I discussed the probability of a right great toe amputation with the patient. He seemed apprehensive Review of Resident #1's Hospital Recordsfor Resident #1 dated [DATE] revealed .Physical Exam General patient is alert no apparent distress. MSK bilateral lower extremities have signs of peripheral [CONDITION(S)]. The right great toe does have sensation slightly diminished secondary to [CONDITION(S)]. There is signs of chronic infection to the area with ulceration purulence and foul smell Review of Hospital Records for Resident #1 dated [DATE] revealed [AGE] year-old males presents to the operating room for right great toe amputation .Pre-Op Dx: Right great toe infection Review of Pathology Report dated [DATE] revealed .A. Right great to amputation for infection: - Skin ulcer complicated by underlying chronic [CONDITION(S)]. -Viable surgical margin Interview with DCO on [DATE] at 8:30am revealed Resident #1 went to the oncologist and examined his foot. The toe had a wound on it they though was [CONDITION(S)]. DCO stated she had no idea about the toe. She talked with the CNA who noted no complaints and did not notice anything. As far as she knew there were no issues, no wounds or open areas. DCO explained that Wound Care Nurse completes all the weekly assessments on everyone. She stated He's (Resident #1) under the radar, chill and really doesn't come out of his room. Was on hospice but came off because he wanted treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . DCO indicated Resident #1 would take showers and there were no problems with his refusals. DCO explained on [DATE] Family Member A called her after Resident #1 was in the hospital. She stated it was the first time to speak with Family Member A and she reported that Resident #1 lost his toe, and someone should be held accountable. Resident #1 went to doctor office and then was sent to the hospital. After receiving this call DCO stated It's apparent something happened. She had a skin sweep conducted and no other areas of concern were found. The skin sweep was conducted by the ADCO and Wound Care Nurse, DCO was unable to state if they conducted the skin sweep together or if they divided the residents up to do skin assessments. Wound Care Nurse was re-educated and in-service when Resident #1 went to the hospital regarding skin assessments. DCO explained resident bathing occurs ,d+[DATE] times per week. She was unable to verify the schedule. All showers should be documented in the POC. DCO stated she did not look at Resident #1's showers. DCO clarified CNAs should notify a nurse if they find anything abnormal with a resident's skin during a shower or during care. DCO stated she did not think the facility had any failures but thinks ultimately that him (Resident #1) coming off hospice that we don't do aggressive treatment. We missed that. We should have followed through with aggressive treatment. He may had had a small gangrenous spot on his foot, and it was missed. Interview with ADCO on [DATE] at 9:50 am revealed she had been working the floor a lot as a nurse due to call-ins. She stated she was familiar with Resident #1. She described him as be an angry man because of his diagnosis. Kind of grumpy. She had never seen his feet. She did not know if he wore socks and shoes. She stated she was made aware of the toe amputation and [CONDITION(S)] on Resident #1. She and the Wound Care Nurse did skin assessment together. This entails a full body check with checking all orifices. They went head to toe including cracks, back sides, behind ears, feet and in between toes. They did not discover anything that was not already being treated. Only saw residents had dry skin. ADCO explained there were weekly skin assessments to be conducted by the Wound Care Nurse and this would include ensuring nails were cut, clean and appropriate. They left toenails for the podiatrist. She stated the nursing team did look at the feet. CNAs should be checking daily and reporting if there is anything abnormal. Interview with Wound Care Nurse on [DATE] at 10:11am revealed when a resident was sent to the hospital a skin assessment is to be done. She stated that Resident #1 had one pop up very late. She stated she did a skin assessment on [DATE] on Resident #1. She was providing no treatments for Resident #1. Wound Care Nurse explained she was out due to COVID and was trying to catch up and could've missing something. She explained the week beginning with [DATE] she was back doing wounds and assessments. Wound Care Nurse explained when she conducts skin assessments she starts with a resident head and goes all the way down including behind ears, arm pits, in between toes, on the heels, and under breasts. She stated that some residents would not allow you to take their socks off but if this was the case, she would document it in the nurse's notes. She explained some residents would refuse occasionally and then she would go back and try until a resident would get agitated. She would then document this information in her notes. She stated she has felt rushed and had so much to catch up with and overwhelmed and could've missed something with regards to Resident #1. She stated she did not ask for help. She stated she assumed they would do skin assessments while she was out. The building was dealing with COVID at the time. When she sees overdue assessment pop up on UDA (form) list they would be in a row and she would catch them up for that date. If she wasn't in the building for the assessment, she would interview the CNA and/or nurse to see if there were any areas of concern to catch up documentation. Wound Care Nurse stated, as far as she was aware there was nothing wrong with Resident #1's toes but feels she could've missed something. Interview with CNA B on [DATE] at 10:27am revealed she worked with Resident #1. She explained Resident #1 spent most of his days in bed unless he had a doctor's appointment and would occasionally get up in his wheelchair. CNA B stated Resident #1 took baths on the second shift and that she did not bath him. Resident #1 previously would get up for baths with hospice. She stated she would get Resident #1 dressed in the mornings when he had a doctor appointment. She stated on [DATE] Resident #1 left early, she did not dress him for the appointment. Resident #1 would let them know when he wanted his clothes changed. He generally wore a gown and t-shirts. CNA B stated she did not change Resident #1's socks on the day he went to the doctor. CNA B explained Resident #1 was alert and oriented and able to make his needs known. He was on hospice, but it stopped a month ago. She did not see the Hospice Aide come in but thought she did care in the evenings. Resident #1 did not refuse care, he had pretty good hygiene according to CNA B. CNA B stated she would change his shirts daily, would do incontinent care and help shave him. Resident #1's socks were changed on shower days. Telephone interview with LVN C on [DATE] at 10:45am revealed she was familiar with Resident #1. She did not work with him on [DATE] but did work with him the day before. She stated he did not like to come out of his room. But on [DATE] he did get up to his wheelchair. She explained when a resident had an appointment it was put into an online system, it is put in 24-hour report and then the CNAs are notified 30 minutes to an hour before the appointment. CNAs get the resident up and resident for the appointments. LVN C stated she did not do skin assessments. She stated no wound had been reported to her on Resident #1 except for when he was first admitted . LVN C was unable to state when she had last seen Resident #1's feet. Telephone interview with CNA D on [DATE] at 11:13am revealed he worked with Resident #1. He helped take care of basic needs, give food, change, shave and give showers to residents. CNA D stated he gave Resident #1 a shower the night before his doctor appointment, [DATE]. He took Resident #1 to the shower room. He said that the first time he bathed Resident #1 there was concern of him itching so he had to get a special body wash. There had been no other complaints of itching. CNA D stated he always looks at the resident's skin. He stated he did not see anything notable with Resident #1's skin. CNA D stated he saw and washed Resident #1's feet and they were fine. They seemed ok to him. He stated Resident #1 does refuse his showers on the weekend. CNA B explained if he found anything abnormal with a resident's skin, he would tell the nurse and document. He stated every time he gives a shower it is documented in the kiosk. There is also paper forms but he did not have those when he last bathed Resident #1. Interview with LVN E on [DATE] at 1:18pm revealed she did not work fulltime for the facility. She stated she knew Resident #1 went to a doctor appointment on [DATE]. She stated Resident #1 was gone by the time she came work and stated she thought he had two appointments. LVN E stated she did not see Resident #1 at all that shift. LVN E stated she had cared for him during month (specific date unknown) and he appears to be hot so she tried to get him to get up in wheelchair. Resident #1 would tell her he was fine. She attempted to check his brief and he would tell her he was fine. She raised his pant leg and Resident #1 told her to put it down. Resident #1 worse no skid socks so she did not ever see his feet. Interview with CMA F on [DATE] at 1:41pm revealed she passed medications to Resident #1 on [DATE] and thought he was already up and in his wheelchair. She did not remember his appearance. She stated he had dry skin and would scratch a lot. Resident #1 was noted to stay in bed most days. Interview with CNA G on [DATE] at 2:30pm revealed Resident #1 had an appointment last week. She stated she got him up out of bed. The transport company came to get him for his appointment. CNA G stated CNA B had been working with him because she was having to deal with another resident. Resident #1 was noted to have had a t-shirt and socks on. CNA G helped him put on his sweatpants and placed his red slipper boots over his socks. CNA G stated Resident #1's socks were clean, and she did not see his feet. There did not appear to be drainage coming through the sock. CNA G stated she normally worked the ,d+[DATE] shift and stated that Resident #1 normally got a shower in the morning. She stated that recently the schedules had changed for showers. She said A beds get morning showers and B beds get afternoon showers. She stated Resident #1 always had a shower in the morning. She stated Resident #1's hygiene appeared to be adequate, and he had no odors. CNA G does not remember seeing Resident #1 with his socks off. She explained she would document in the computer when she gave a shower to a resident and helped with other ADLs. She stated Resident #1 was not resistant and did not refuse care. CNA G stated Resident #1 would ask to be changed and he liked to be changed frequently. Interview and observation, on [DATE] at 2:45pm of Resident #1 revealed he was still in the hospital. Family Member A and Family Member H were at his bedside. Resident #1 was alert, smiling and would answer questions. Resident #1 was hard of hearing. He was noted to have his right foot bandaged up which Resident #1 said he had to have his toe amputated. Resident #1 stated he was doing good. When asked how it was at the facility Resident #1 furrowed his eyebrows and did not say anything further. He stated the staff was ok with helping him. When asked how often he was bathed at the facility he stated never in a matter-of-fact manner. Resident #1 showed his legs, and his skin was noted to be clean and moist. He stated he had a bath and it felt good. Interview, on [DATE] at 2:45pm with Family Member A and Family Member H explained they visited Resident #1 at the facility most evenings or every other evening, except for a two-week period when the facility was experiencing COVID. Resident #1 is described by the family as someone who did not like to complain and most of the time did not like to be bothered. When they would visit him, he would ask for help with changing his t-shirt because it would be dirty and would complain he had not had a bath. Family Member A explained on [DATE] Resident #1 had an appointment with his Internal Medicine Physician, who had seen for several years. The Internal Medicine doctor had not seen him in a while, so he wanted to check Resident #1's right ankle where he had [CONDITION(S)] removed in [DATE]. Family Member H showed a picture of the wound that was healed, with clean edges, and described it as being about the size of a quarter. Family Member A went on to explain Internal Medicine doctor took off Resident #1's socks in the office. The sock appeared to be clean but Resident #1's skin was peeling like a snake and his sock was stuck to his right great toe. When the sock was removed the great toe started to bleed. The toe was described to be black and there was foul smell coming from the wound. Family Member A stated the wound smelled like decay. Internal Medicine Physician diagnosed Resident #1 with [CONDITION(S)] to the top of the food and noted he was concerned about infection and the condition of the toe. Resident #1 was admitted to the hospital with [CONDITION(S)] of the toe, [CONDITION(S)], gangrene and possible [CONDITION(S)]. Resident #1 is not diabetic, and he had not seen a podiatrist. Resident #1 did not complain to his family about pain to his feet and the family stated we never thought to take his socks off and look at his feet as they started to cry. Family Member A stated the hospital nurses reported to them that Resident #1's hygiene was poor when he arrived. He was very unkempt, unbathed and his skin was in poor condition. Interview with Wound Care Nurse on [DATE] at 9:10 am she worked in the facility a year, stated resident skin is assessed weekly, upon admission, and when there is a discharge to another facility, stated the admission nurse will assess a resident skin upon admission and the next day she will also assess the newly admitted resident skin, stated the aides also when providing ADL care will notify her of any skin issues. She indicated skin issues she documents are redness to the skin, DTIs, anything that is not supposed to be on a resident skin, any abnormalities to the skin, any open areas, stated she documents any skin assessments in electronic charting skin assessment, and should a resident have a wound she documents the assessment in an electronic wound assessment. She stated when a resident has a wound, she notifies the DON, physician, and a decision is then made to get the wound care physician involved. Interview with PA on [DATE] at 1:50pm revealed the last time he saw Resident #1 was [DATE], stated he rounds on residents at the facility and Resident #1 every two weeks, stated when a resident has a skin issue in the facility the nursing staff and or resident will notify him of the skin concern. Stated he was not alerted of Resident #1 having any skin issues to his right toe or elsewhere. Stated should he be notified by staff identifying potential [CONDITION(S)] he would have assessed the resident possibly started treatment with antibiotics and depending on the resident's comorbidities gotten the wound care physician involved. Interview with NP on [DATE] at 3:01pm revealed she visits with resident every other week and stated she was in the facility two weeks ago. Stated she without her notes could not definitively state the last time she had seen Resident #1, but to refer to her notes. Stated she expected to be notified by the nurse if a resident had any skin issues, she indicated the facility had standing orders to weekly assess a resident's skin. She stated the facility was pretty good at notifying her of any skin issues present with residents. She stated not being notified of any skin issues Resident #1 currently had or had in the past. Stated she did not have her notes but by her recollection Resident #1 had no current wounds she was made aware of. Stated she also had no notification from Resident #1 or facility staff he was not being showered, nor did she suspect he was not being showered when visiting with the resident. She stated should a resident have suspected [CONDITION(S)] and or gangrene she would expect the nurse to notify her of the skin concern. She had not been notified of any skin concerns with Resident #1. Review of Policy on Skin Management: Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . PROCEDURE 1. General Guidelines .skin assessments will be documented at a minimum of every 7 days on a weekly Skin Assessment. Braden Score will be completed weekly x 4 weeks upon admission/readmission, month and with significant changes in condition. Residents at risk for developing pressure ulcers based on the Braden Score will have care plan developed to include interventions to prevent skin breakdown. Monthly Pressure and Non-Pressure Log will be updated weekly and sent to Regional Director of Clinical Operations on Friday .2. Prevention: Braden Scores will be completed monthly after admission to determine changes in risk category .3. Notification: Resident Care Providers will complete a Stop and Watch form in Point of Care from the resident's chart, which alerts on the nurse's clinical dashboard. A licensed nurse will address the alert after completing and assessment of the resident's skin area and complete the e-INTERACT Change of Condition form for newly identified wounds .A license nurse will notify resident's physician, responsible party, and hospice nurse if on services, with new onset of wounds or deterioration in wound status. Communication of new wounds will be relayed during shift-to-shift report for 24 hours .4. Treatment: A licensed nurse will obtain orders from physician for new skin wounds and transcribe onto resident's treatment record for follow-up .5. Documentation: Skin condition(s) will be addressed on resident's 48 Hour Baseline Plan of Care upon admission by the licensed nurse and preventative measure will be implemented. Weekly skin assessments will be documented on the Weekly Skin Assessment every 7 days or less. Wounds will be documented on the Weekly Wound Assessment every 7 days or less to include length, width, depth, surrounding skin, and wound bed. PUSH score will help assist to determine progress of wound. Licensed nurse will initiate the schedule for the wound form in Point Click Care which automatically triggers every 7 days of completion. Rashes, skin tears, bruises, and other non-wound areas will be documented on the Weekly Skin Assessment. Care plan will be developed by the IDT to include risk factors, interventions to promote skin wellness, and healing of pressure ulcers. All wounds will be documented on the Monthly Pressure and Non-Pressure Log for tracking and trending purposes Review of Med-Pass Policy dated Revised [DATE] on Change in a Resident's Condition of Status provided by the DCO on [DATE] as the facility's policy reflected Policy Statement Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) Policy Interpretation and Implementation 1. The nurse will notify the residents Attending Physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of an unknown source .d. significant change in resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly .2. A 'significant change' of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not 'self-limiting') b. Impacts more than one area of the resident's health status c. Requires interdisciplinary review and/or revision to the care plan; and d Ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source; b. There is a significant change in the resident's physical, mental, or psychosocial status .5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. 6. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments .8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status An IJ was identified on [DATE] at 1:07pm the [NAME], and DCO were notified of the IJ and plan of removal to remove the immediacy was requested at that time. Review of the Plan of Removal dated [DATE] reflected the following: On February 22, 2022 at 1:12pm an Immediate Jeopardy was called for allegations of alleged noncompliance with tag F641 Accuracy of Assessments and F684 Quality of Care resulting in a serious adverse outcome. The resident in question is [Resident#1]. Executive Director of Operations- Notified [Medical Director] of Immediate Jeopardy on F641 Accuracy of Assessments and F684 Quality of Care at 1:56pm [DATE]. Inservices Provided: Corporate educator- Inserviced Director of Clinical Operations concerning the Braden Scale, Accurate Weekly Skin assessments and Head to Toe Assessments. Director of Clinical Operations- Inserviced Assistant Director of Nurses and Wound Care Nurse on Braden Scale for Predicting Pressure Sore Risk Assessment purpose and that it will be performed monthly- completed [DATE]. Director of Clinical Operations - Inservice Treatment Nurse in Accuracy in Assessment and assign further education concerning accuracy in assessments and documentation utilizing the Relias Training Portal. - completed [DATE]. Director of Clinical Operations - Inservice nursing staff; nurses, routine agency nurses, certified nursing aides, routine agency certified nursing aides, non-certified nursing aides, certified medication aides on the importance of providing activities of daily living, consistent documentation, stop and watch reporting, and physician notification of change by [DATE]. Director of Clinical Operations - Inserviced Assistant Director of Nurses, Wound Care Nurse, staffing coordinator and director care nurses that if they see the wound care nurse has been taken off the daily assignment sheet that they are to complete the weekly skin assessments and wound care assigned for that day in their designated area. - completed [DATE]. AMT Wound Specialist- Inservice provided to nursing staff; nurses, routine agency nurses, certified nursing aides, routine agency certified nursing aides, non-certified nursing aides, certified medication aides on Accuracy of Assessments and Wound Care Documentation- scheduled [DATE] @ 2:00pm. Corporate Educator- Changed schedule in PCC for Braden to be assigned monthly- completed [DATE].Corporate Educator-Adding all showers to Point of Care activities of daily living documentation portal. -completed [DATE]. Assistant Director of Clinical Operations -New Braden assessment to be completed for all residents today. - completed [DATE]. Staffing Coordinator- Will add Wound care nurse to daily assignment sheet. If Wound Care nurse calls in, takes PTO or is absent for any reason the staffing coordinator will reflect her absence by removing her from the daily assignment sheet. - completed [DATE]. Assistant Director of Nursing & Wound Care Nurse-Will w [TRUNCATED]

Based on observation, interview and record review, the facility failed to maintain an effective pest control program for three (Residents #1, #2 and #3) of seven residents reviewed for environment. 1. The facility failed to ensure Resident #1, #2 and #3 were cared for in an environment that was free of bed bugs on multiple dates. 2. The facility failed to provide Resident #1 an environment that maintained her quality of life. On 02/07/20 Resident #1 was identified as suffering from bed bug bites and bed bugs were found on her belongings and wheelchair. The infected wheelchair was used to transport Resident #1 to room [ROOM NUMBER]. Following this incident Resident #1 began to display increased anxiety, fearfulness, and depression. On 02/19/20, Resident #1's second room, room [ROOM NUMBER], was found to have an active infection of bed bugs. On 02/26/20, Resident #1 had bed bug shells and eggs on her recliner. These incidents resulted in Resident #1 having increased anxiety, sleeplessness and depression. Resident #1 lost her personal belongings due to bed bug infestation. These failures placed residents at risk of bed bug exposure. Findings included: 1. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She had a BIMS of 15 indicating she was cognitively intact. She required limited assistance with ADLs. Review of Resident #1's Comprehensive Care Plan undated reflected the resident had a history of [REDACTED]. Review of Resident #1's Nurse notes reflected the following: -written by LVN A dated 02/07/20 at 3:07 AM revealed (Resident #1) was complaining of itching. This nurse looked in the area she stated was itching and multiple bites to her neck, upper back, right side and upper bilateral arms. On her recliner I observed 12 large bugs crawling on her chair. There were small bugs on her wheelchair. Resident was moved to an empty room and given a different chair to sit in. Resident is resting with no needs voiced at this time. Family, administer and DON notified. -written by Admin dated 02/07/20 at 8:32 AM revealed pest control called and residents moved to another room. -written by DON dated 02/07/20 at 11:26 AM revealed Resident #1's physician's office called notified that resident room was found to have bed bugs. Currently has orders for [MEDICATION NAME] 50 mg po TID (three times daily) prn and [MEDICATION NAME] cream every 4 hours topically as needed for itching seeing if he wanted any additional orders. -written by ADON dated 02/18/20 at 3:25 PM revealed (Resident #1) at nurses station with daughter present, resident noted to be crying and visibly upset r/t (related to) bug issue. This nurse comforted this resident and educated on bug. This nurse got resident new wheelchair. NP present at this time and spoke with resident. New order to increase [MEDICATION NAME] 0.5 tid (three times daily) x's 14 days. Resident and family aware and will be put on 24 hour report to carry over to shift, pharmacy notified. -dated 02/26/20 at 5:16 PM revealed talked with resident daughter and notified that resident room will be treated by pest control for bed bug eggs in the am of 02/27/20 and resident will have to be out of the room for 6-8 hour during this time. That all of her laundry will be washed in hot cycle and her room has had a deep clean done on it. Review of Resident #1's Weekly Skin assessment dated [DATE] completed by LVN B reflected Resident #1 had a yeast rash present to bilateral breast folds and groin region. She had red bumps to left shoulder and upper chest area. BLE 1+ with redness. Review of Resident #1's MAR/TAR for February 2020 and March 2020 dated 03/03/20 reflected she received [MEDICATION NAME] tablet 0.5 mg ([MEDICATION NAME]) give 1 tablet by mouth three times a day for anxiety starting on 02/18/20 at 7 PM through 03/03/20. Resident #1 received [MEDICATION NAME] 0.25 mg give 1 tablet by mouth three times a day for anxiety, agitation with state date of 10/07/19 and discontinued date of 02/18/20. Review of Resident #1's Behavior Note dated 02/17/20 by Psychiatric Services reflected (Resident #1) being seen today for anxiety, depression/sadness and [MEDICAL CONDITIONS] .(Resident #1) reports 'I'm just sad that are my valuables are in a shed.' Staff report manageable behaviors. Patient's room needed special cleaning and care related to bed bug invasion. All furniture and any other objects that may be housing the bugs will not be returned to the room .Patient is having difficulty adjusting to moving to another room temporarily. She is not wanting to move back when the room is ready .Per staff, the patient has struggled with the stated adjustments, she is periodically tearful and tends to isolate in her room. Review of Resident #1's initial psychotherapy assessment dated [DATE] reflected goals for therapy including reducing symptoms of [MEDICAL CONDITIONS] type, depression, anxiety, preventing/reducing decline due to limited coping skills and reducing impairment due to unstable mood. Psychotherapy is recommended 1-2 times a week. Review of Resident #1's psychotherapy notes reflected she was seen on 01/29/20 and 02/03/20 prior to bed bugs found in resident's room. Review of Resident #1's psychotherapy note dated 02/10/20 reflected Resident #1 has displayed symptoms such as adjustment difficulty, anxiety, depression, hallucinations, sadness, sleep disturbance, withdrawal .Pt. temporarily relocated to a new room. Pt expressing difficulty adjusting to changes. Review of Resident #1's psychotherapy note dated 02/19/20 reflected Resident #1 has displayed symptoms such as adjustment difficulty, anxiety, depression, hallucinations, [MEDICAL CONDITION], sadness, sleep disturbance, withdrawal and (Resident #1) stated 'I can't handle stress'. It reflected Resident #1 continues to see and feel bugs due to recent bug exposure. Pt shared that she is working towards differentiating between what is 'real' and 'not real'. Pt shared that she expects to have difficulty adjusting to a new room arrangement. Pt shared that she was tearful on day prior to session and pt's PA prescribed [MEDICATION NAME] for pt's anxious mood. Pt stated 'I can't handle stress'. Pt shared that medication increase recommended by psycho NP has not yet been approved by patient's daughter. Review of Resident #1's psychotherapy note dated 03/02/20 reflected Resident #1 has displayed symptoms such as adjustment difficulty, anxiety, depression, hallucinations, [MEDICAL CONDITION], sadness, sleep disturbance, withdrawal and (Resident #1) stated, 'I haven't slept in two days and 'I'm scared'. It reflected she expressed feelings of depression, anxiety, and fear related to the 'bugs'. Pt shared that bugs were found on her bed when pt was relocated back to her prior room. Pt reported appetite and sleep disturbances related to the 'bugs'. Pt was able to differentiate between reality and out of touch thinking. Pt reported an increase in pt's AVH and paranoia. Pt stated 'I'll never be the same. It reflected goals for therapy including reducing symptoms of [MEDICAL CONDITIONS] type, depression, anxiety, preventing/reducing decline due to limited coping skills and reducing impairment due to unstable mood. Psychotherapy is recommended 1-2 times a week. Review of Resident #1's social service note dated 10:23 AM by social worker reflected (Resident #1) reports feelings of sadness and helplessness currently. She reports hallucinations - get away from the bugs. SW notified psychiatric services, DON and ADON. Review of Resident #1's Social plan update note dated 03/02/20 at 4:00 PM by social worker reflected Resident visited with (Psychiatric Services) today. Per (Psychiatric Services) patient reports AVH, depression and fears are related to bug situation. Pt reported belief that once the bug issues is resolved this will provide relief. Pt reported that she has not slept for the past two days, in fear of the bugs. Appropriate support provided. Psych will manage medication management. Pt reported a change in pt's appetite for last two days as well. SW notified DON and ADON. Observations on 02/27/20 at 10:53 AM and 02/28/20 at 3:48 PM revealed Resident #1 had no skin issues. Interviews on 02/27/20 at 10:55 AM and 03/03/20 at 1:30 PM with Resident #1 revealed she was itching a lot on 02/07/20 at night and wanted [MEDICATION NAME] cream. She stated the nurse looked at her, finding bed bug bites all over her upper arms and back. She stated the nurse turned on the lights in her room and she could see many bed bugs on Resident #1's recliner, wheelchair, floor and curtain. Resident #1 said she started crying and she felt like the bed bugs were on her all the time and felt dirty. She stated she showered every day. She stated they found the bed bugs in my new room and she did not understand why they followed her. She stated she lost all of her personal items, including a bible which was her mother's and could not be replaced. She stated she kept her door open at night because she was afraid of the dark and that was when the bed bugs came out. She stated over the past weekend she found a live bed bug on her window sill and it moved, walking on her bed covers. She stated she informed the nurse on duty who caught the bed bug and killed it. She stated she and her roommate were moved to a different room right afterwards and she did not want to go back to the other room because she kept remembering seeing all those bed bugs that night. She stated she was having difficulty sleeping since the bed bugs were found in her room and had been scared she would get bit at night over the last couple of weeks. At that time Resident #1 started crying and said she felt helpless and last night slept near the nurse's station in her wheelchair the night before. She stated she keeps her door open at night because she is afraid of the dark that's when the bed bugs come out. She stated over the past weekend she found a live bed bug in her window seal and it moved walking on her bed covers. She stated she informed nurse who caught it and killed the bed bug. She stated she and her roommate were moved back to room [ROOM NUMBER] from room [ROOM NUMBER] right afterwards. She stated she did not want to go back to room [ROOM NUMBER] because she remembers seeing all those bed bugs that night. She stated she checked her clothes before she put them on daily and looked everywhere to ensure bed bugs were not there. She stated she had been through a lot of things but nothing like the bed bugs. She stated she felt like the bed bugs followed her and they keep finding them in her room. Interview on 02/27/20 at 11:46 AM with CNA H revealed on 02/06/20 on the 6 am to 2 pm shift she found a bug on Resident #2's pillow but she did not know what kind of bug it was so she took the pillow with the bug on it to Med Aide J who told her it looked like it was a bed bug. CNA H stated she bagged Resident #2's linen, sheets and pillow. She put new linen and pillow on Resident #2's bed. She stated it was reported to the DON. Interview on 02/27/20 at 11:57 AM with Med Aide J revealed on 02/06/20 CNA H brought Resident #2's pillow with a bug on it to her because she did not know what kind of bug it was. She told CNA H it looked like an apple seed with legs (bed bug) and told her to change Resident #2's linen and pillow. She stated she informed the DON about the bug they found believing it was a bed bug and assumed Maintenance Director was informed. Interviews on 02/27/20 at 1:23 PM and 02/28/20 at 1:20 PM with DON revealed CNA H showed her a bug on Resident #2's pillow in the morning and the staff thought it was a bed bug on 02/06/20. She stated she told staff to replace the linens and pillow. She logged it in the Maintenance log and stated she thought she informed the Maintenance Director. She stated in the middle of the night Residents #1 and #2 were moved to another room due to bed bugs. She stated Resident #1 complained of itching and had red bumps on her arms and back on 02/07/20. She stated nurse provided cream to resident for itchiness and bumps. She stated on 02/19/20 pest control was called out due to Resident #1's wheelchair having bed bugs on it. She stated she did not know when Resident #1 got her wheelchair back after 02/07/20. Interviews on 02/27/20 at 10:05 AM and 02/28/20 at 1:35 PM, the ADM stated pest control came out on 02/07/20 initially for room [ROOM NUMBER] where they confirmed live bed bugs were found. She stated Residents #1 and #2 were moved out of the room in the middle of the night. She stated the facility had the whole facility preventatively treated for [REDACTED].#1's wheelchair because staff thought there were bed bugs. She stated the wheelchair and room [ROOM NUMBER] were treated. She stated on 02/26/20 pest control dog alerted rooms [ROOM NUMBERS]. Interview on 02/28/20 at 10:30 AM with the Business Office Manager revealed she was informed the morning of 02/07/20 the Resident #1 and Resident #2's room (room [ROOM NUMBER]) had had bed bugs. She stated at about 7:20 AM or 7:30 AM she went down to the residents' room and the door was shut with a blanket on the ground in front of the doorway. When she entered, she saw about 4 dead bugs; 1 on Resident #2's bed and 2 on the floor. She stated she did not look closely at the recliner. She called the Administrator and pest control came out later that same day and confirmed it was bed bugs. Interviews on 02/27/20 at 4:17 PM and on 03/03/20 at 10:34 AM with LVN B revealed the facility did a full skin sweep on all residents on 02/25/20 due to a scabies outbreak and bed bugs. She stated on 02/07/20 on the 6:00 AM to 2:00 PM shift she completed a skin assessment on Resident #1 which revealed she had red bites on one shoulder and her upper chest area. She stated on 02/07/20 Resident #2 had red bites on her ankles but denied any itching. She stated Resident #1 had increased anxiety and her [MEDICATION NAME] was increased since finding bed bugs in her room. She stated on 02/25/20 when she completed Resident #1's skin assessment, Resident #1 asked her, Are the bugs inside me?, and, Could I ingest the bugs? She told Resident #1 she could not visually see any bugs on her. She stated Resident #1 asked her if she (the resident) caused the bed bugs. She stated the bed bugs came back into her room again and she constantly worried about having bugs on her. Interview on 02/27/20 at 2:42 PM and on 02/28/20 at 3:33 PM with ADON revealed on 02/06/20 LVN A or LVN C notified the DON or LVN B about Resident #1 having multiple red bites on her and complaining of itching. She stated the nurses saw numerous bed bugs in Resident #1 and Resident #2's room, including bugs on Resident #1's recliner where she slept, wheelchair, floor and curtains. She stated Residents #1 and #2 were moved to a new room. She stated Resident #1 on 02/18/20 felt dirty and filthy, asking if the bed bugs were inside her. She was crying and visibly anxious with her daughter present. She stated Resident #1 was fixated about the bed bugs and complaining of itching. She stated the nurse practitioner was present at the facility and decided to increase Resident #1's [MEDICATION NAME] to 0.5 mg since her anxiety was getting worse due to the bed bugs. She stated on 02/26/20 she went with the pest control dog who was trained for bed bugs to the resident's new room where the pest control dog triggered by sitting down in front of Resident #1's recliner, and the guy with the dog called it a hot spot. She stated she and the gentleman looked and found bed bug eggs and shells (skins) about 5 inches long on the side seam of the recliner foot rest. She stated Resident #1 was in the hallway and started crying when the dog alerted the recliner had bed bugs. Resident #1 started saying, I am going to lose everything again and was upset they found bed bugs again in her new room. She stated Resident #1 should not have been moved in her wheelchair which had bed bugs to the new room and the nurse should have gotten another wheelchair to transport Resident #1. Interview on 02/27/20 at 2:55 PM with CNA K revealed Resident #1 was upset and cried, telling her and other staff she released the bed bug epidemic since it was first found in her room by night shift. She stated Resident #1 would get upset daily but seemed to be getting past it; however, yesterday (02/26/20) the dog found bed bugs on her new recliner. Interview on 02/27/20 at 12:15 PM with CNA L revealed on the night shift bed bugs were found in Resident #1 and #2's room. She stated Resident #1 had been itching for a while, but no bumps were observed prior to the night nurse finding some. She stated Resident #1 told her they found a bug in her room on 02/06/20. She stated Resident #1 was moved to a new room and did not get her clothes changed. She stated she was not sure what date, but prior to pest control finding bed bugs on Resident #1's wheelchair the second time, Resident #1 got her wheelchair back. She stated that evening after noticing Resident #1 got her wheelchair back, she stated bed bugs were found on the wheelchair. She stated yesterday (02/26/20) the pest control dog found bed bug eggs on Resident #1's recliner in her new room (room [ROOM NUMBER]). Interview on 02/27/20 at 12:10 PM with CNA I revealed Resident #1 was seeming to get better with her anxiety decreasing, but then yesterday (02/26/20) the pest control dog found bed bugs in her room on her recliner. Resident #1 was crying yesterday and felt like the bed bugs were on her. Interviews on 02/28/20 at 1:45 PM and on 03/02/20 at 1:11 PM with LVN G revealed on 02/07/20 on the 6 am to 2 pm shift Resident #1 had multiple reddened bites on her left shoulder, upper chest area (6 or 7 bumps), 3 bumps on right breast and multiple bites on upper arm above elbow. She stated Resident #1's [MEDICATION NAME] was increased from 0.25 mg TID to 0.5 mg TID due to bed bug disturbance and increasing her anxiety. She stated Resident #1 had more difficulty sleeping since bed bugs found especially after they were found again in her room. She stated Resident #1 was afraid people thought she was dirty and caused the bed bugs. She stated Resident #1 did not want to return back to her original room due to seeing all those beg bugs in her room. Interview on 02/27/20 at 2:42 PM and on 02/28/20 at 3:33 PM with ADON revealed on 02/06/20 LVN A or LVN C notified the DON or LVN B about Resident #1 having multiple red bites on her and complaining of itching. She stated the nurses saw numerous bed bugs in Resident #1 and Resident #2's room including bugs on Resident #1's recliner where she slept, wheelchair, floor and curtains. She stated Residents #1 and #2 were moved to a new room. She stated Resident #1 on 02/18/20 felt dirty and filthy asking her if the bed bugs were inside her. She was crying and visibly anxious with daughter present. She stated Resident #1 was fixated about the bed bugs and complaining of itching. She stated the nurse practitioner was present at the facility and decided to increase Resident #1's [MEDICATION NAME] to 0.5 mg since anxiety getting worse due to bed bugs. She stated on 02/26/20 she went with the dog who was trained for bed bugs to room [ROOM NUMBER] where it triggered by bowering up and sitting down in front of Resident #1's recliner and the guy with the dog called it a hot spot. She stated her and the guy looked finding bed bug eggs and shells (skins) about 5 inches long on the side seam of recliner foot rest. She stated Resident #1 was in the hallway and started crying when the dog alerted the recliner had bed bugs. Resident #1 started saying I am going to lose everything again and was upset they found bed bugs again in her new room. She stated Resident #1 should not have been moved in her wheelchair which had bed bugs and the nurse should have gotten a new wheelchair for resident. Interview on 03/03/20 at 11:03 AM with Resident #1's physician revealed Resident #1 did have increased anxiety and nervousness since bed bugs were found in her room. Interview on 03/03/20 at 11:09 AM with Resident #1's Nurse Practitioner revealed on 02/18/20 she did increase Resident #1's [MEDICATION NAME] medication from 0.25 mg TID to 0.5 mg TID for 14 days due to Resident #1 visibly upset, crying and increased anxiety after bed bugs were found in her room. 2. Review of Resident #2's Annual MDS dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She had a BIMS of 15 indicating she was cognitively intact. Observation on 02/27/20 at 4:01 PM of Resident #2 revealed no current skin issues. Review of Resident #2's nurse note dated 02/07/20 at 3:11 AM by LVN A reflected Resident #2 moved to room [ROOM NUMBER] due to possible bed bugs in her room. Review of Resident #2's nurse noted dated 02/07/20 at 11:30 AM reflected call placed to (Resident's responsible party) message was left that resident room was found to have bed bugs .Laundry and belongings will be treated, room is currently being exterminated. Call back information has been left. Call placed to physician's office message left that residents room is positive for bed bugs. Review of Resident #2's skin assessment dated [DATE] reflected Resident #2 had small red spots around both ankles. Review of Resident #2's skin assessment dated [DATE] reflected no skin issues. Review of Resident #2's nurse noted dated 02/26/20 reflected talked with resident's (responsible party) and notified that resident room will be treated by pest contol for bed bug eggs in the am of 02/27/20 and resident will have to be out of room for 6-8 hour during this time. That all of her laundry will be washed in hot cycle and her room has had a deep clean done on it. Review of Resident #2's nurse noted dated 02/27/20 reflected patient day 1 of room change to 104a. Interview on 02/27/20 at 2:49 PM with LVN F revealed he was not aware Resident #3's mattress or bed had been triggered by the pest control dog on 02/26/20 and was told it was the mattress not being used so the facility had thrown out the other mattress not Resident #3's mattress. He stated if he had been told it was Resident #3's mattress or bed he would have the matress removed and Resident #3 moved to another room on 02/26/20. He stated Resident #3 was not moved until today to another room. 3. Review of Pest Control Reports reflected the following: - Dated 02/07/20 room [ROOM NUMBER] had active bed bugs. Treated the room. Facility had concerns for the entire facility and would like it treated for [REDACTED]. Please make sure all personal belongings gets to the family or discard all items in the dumpster to prevent infestation. I will be back to follow up on room [ROOM NUMBER]. Please make sure not one goes into the room. - Dated 02/10/20 treated room [ROOM NUMBER] again for bed bugs. Please keep closed until Wednesday. On Wednesday make sure to deep clean the room. - Dated 02/12/20 A-Hall 101, 102 103, 105, 106, 107, 108, 109, 110 and 111 and B-Hall rooms 201 - 209 and medical records room with preventative biopesticide treatment with apprehend. - Dated 02/13/20 C-Hall room [ROOM NUMBER] - 310 and F-Hall 601 - 611 treated with preventative biopesticide treatment with apprehend. - Dated 02/14/20 D-Hall and E-Hall including rooms 501-510 and dining/common area treated with preventative biopesticide treatment with apprehend. - Dated 02/19/20 Treated the wheelchair outside, had bed bugs. Treated 601, had bed bugs. Everything needed to be rewashed because no one is inspecting items going back into the room Please make sure all items are being inspected. Residents in 601 are the same residents who came from 104. - Dated 02/21/20 Treated 104 again for bed bugs, please make sure that sanitation practices are being implemented at this facility. That inspections are being done on a regular basis on rooms as well as residents. To further help combat the bed bugs, facility has authorized for a k-9 to inspect for bed bugs on 02/26/20. - Dated 02/26/20 K-9 had 2 hits in room [ROOM NUMBER] and 601. Recliner was removed in 601 and both rooms will be treated. Please make sure the bed bug protocol is completed. - Dated 02/27/20 Treated room [ROOM NUMBER] and 509 for bed bugs. K9 alerted to these rooms being infested. All other rooms were clear. No activity at this time. - Dated 03/03/20 Treated 104, said to have live bed bugs. Asked the Administrator to oversee the cleanup for room [ROOM NUMBER]. Found 6 dead bed bugs. No activity at this time. Interview on 02/28/20 at 11:29 AM with Pest Control Technician revealed he was called by the facility on the morning of 02/07/20. He treated room [ROOM NUMBER] and found many live bed bugs on 02/07/20 and confirmed it was a bed bug infestation. He stated he sealed off the room and all personal items were to be bagged and not to return to the room due to risk for infestation. He stated the recliner had to be thrown out. He stated he returned to the facility to treat 104 a second time on 02/10/20 and told them the room needed to be deep cleaned on Wednesday. He stated the facility wanted the whole facility to be preventatively treated, so he did 2 halls at a time from 02/12/20 to 02/14/20. He stated he came back out to the facility on [DATE] to treat the wheelchair where dead bed bugs were found and room [ROOM NUMBER]. He stated on 02/26/20 a pest control dog came out and alerted in room [ROOM NUMBER], including a pillow on 601A bed. He stated they found live bugs and eggs on the recliner in room [ROOM NUMBER]. He stated room [ROOM NUMBER]A was alerted on the bed including the mattress and pillow. He stated he informed the facility to bag personal items and he treated rooms [ROOM NUMBERS] on 02/27/20. He stated if the facility staff pushed the resident in her wheelchair with bed bugs from her old room to her new room, then they contaminated her new room. Observations on 02/28/20 of 5 of 5 resident rooms, 300 hart linen cart and 2 of 2 linen storage closets revealed no bed bugs found. 4. Review of Bed bugs: Strategies to Minimize the Spread policy dated June 2016 reflected to 1. reduce clutter .Be sure to seal anything you are going to remove from an infested area tightly in garbage bags to avoid spreading the infestation to another part of your home. Disinfect and properly store items you want to keep. 2. Seal cracks and crevices around baseboards, window molding, furniture joints, etc. to keep bed bugs from hiding in them. 3. Caulk and seal all holes where pipes and wires come into the room to prevent bed bugs from migrating in along pipe and wiring runs. 4. Don't use the area around the bed for storage. Review of article NPMA (National Pest Management Association) Guidelines Response to bed bugs in medical facilities developed by the National Pest Management Association undated reflected the following: Responding to a Bed Bug Incident o If bed bugs are reported or suspected, do the following: - Get specimens, if possible, for professional identification. - Arrange for an inspection as soon as possible by a qualified pest management professional. o If the report is from a patient room: - Move the patient and take the room out of service. - Inspect personal items for bed bugs before moving patients to a new room and offer to wash or dry clean their clothes. - Medical equipment (wheel chairs, IV stands, etc.) and beds should not be moved to the new room unless they can be verified as not containing any bed bugs. - A pest management professional should inspect the suspect room, adjacent rooms, the patient's new room, all furniture and equipment, and lounge and public areas the family may have been using. o Bed bug service must take into consideration the potential health impacts of insecticide on patients who are ill. - Emphasize non-chemical control measures. - If insecticides must be used, use only those products and methods approved by the facility, and only in unoccupied rooms. - Incorporate non-chemical methods such as steam treatment, heat, aggressive cleaning and laundering, and targeted vacuuming wherever practical. - Medical equipment and furniture is best disinfested with heat or fumigation off-site. - Mattresses and box springs can be steamed, protected with bed bug proof encasements, heat treated in a chamber, fumigated, or discarded. o Bed bug service is not complete after a single service visit. - Rooms that have been serviced for bed bugs should be rescheduled for follow-up inspection, re-serviced as needed, and kept off-line until the bed bugs have been successfully controlled. - Affected rooms and adjacent rooms should be inspected for 2-3 months to ensure that no isolated pockets of bed bugs remain. Consider the installation of bed bug detection devices or bed bug scent detection canine teams. - Also inspect waiting rooms, laundry rooms, lounges, cafeterias, children's play areas, and other areas as appropriate.

Based on interviews and record reviews, the facility failed to ensure that based on the comprehensive assessment of a resident, the facility ensured residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered plan of care and the resident's choices for one (Resident #1) of seven residents reviewed for quality of care. The facility failed to thoroughly assess Resident #1 after he had multiple falls on 04/30/18. The facility failed to transfer Resident #1 to the emergency department in a timely manner. Resident #1 was transferred to a hospital on [DATE] and found to have sustained a subdural hematoma (bleeding of the brain), multiple right sided rib fractures with a right sided pneumothorax (lung collapse) and a left [MEDICAL CONDITION]. Resident #1 was transferred to another hospital for trauma and neurosurgical services. An Immediate Jeopardy (IJ) was identified on 05/04/18. While the IJ was removed on 05/08/18, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of isolated because the facility was still monitoring the Plan of Removal. These failures could affect 21 residents who fell in (MONTH) (YEAR) by placing them at risk for not receiving emergency care, as needed, which placed them at risk of serious injury, harm or death. Findings included: Review of the MDS assessment, dated 03/01/18, revealed Resident #1 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. Resident #1 had moderate cognitive impairment, required extensive assistance with ADLs, supervision with eating and locomotion, limited range of motion of upper extremities, self-propelled in a wheelchair and was incontinent of bowel and bladder. The resident had behavioral symptoms directed towards others. His [DIAGNOSES REDACTED]. Review of Resident #1's clinical record revealed no evidence of a fall assessment. Review of the care plan initiated on 02/02/18 revealed Resident #1 had a history of [REDACTED]. Review of the facility report, Incident by Date, dated 05/08/18, revealed one Incident Report dated 04/30/18, was completed for a fall in the room of Resident #1 that occurred at 6:45 AM. There were no additional Incident Reports regarding incidents involving Resident #1 for 04/30/18 or 05/01/08. Review of the Incident Report, dated 04/30/18, revealed on that date at 6:45 AM, Resident #1 was found on the floor in his room and was yelling for help. The resident was bleeding from the middle of his forehead. He had blood to his face and both arms and legs. Resident #1 sustained a laceration to the top of his scalp and a bruise on his abdomen. LVN C conducted a head to toe assessment, performed neurochecks and a pain assessment. LVN C completed a fall risk assessment. The report reflected Resident #1 was trying to find his wheelchair. Review of the nurses' note, completed by LVN C on 04/30/18 at 10:46 AM, reflected Resident #1 was found yelling in his room on the floor. The note reflected the resident was bleeding from his mid-forehead, continuously wiping his forehead with the bed linens. The staff assisted the resident back to bed. LVN C documented the resident sustained [REDACTED]. The physician was notified, and new orders were obtained. LVN C documented a pressure dressing was applied to the forehead and she cleaned the resident's face and both arms. Vital signs were 127/67, pulse 89, respirations 20, temperature was 99.5 Fahrenheit. Oxygen saturation was 96%. LVN C performed neurochecks and noted multiple bruises of multiple sizes and colors to both arms and legs, and the torso was bruised with red, blue and purple in colors. Review of the physician's orders [REDACTED].#1 revealed, .Laceration to mid, top forehead; cleanse with NS (normal saline), pat dry with 4x4 gauze, apply compress until bleeding stops. Interview with LVN C on 05/01/18 at 2:02 PM revealed the above nurse's note, entered on 04/30/18 at 10:46 AM, related to the fall that occurred that morning at 6:45 AM. She stated Resident #1 routinely needed assistance with transfer from the bed to the wheelchair, ate meals in the dining room, and was continent of bladder and incontinent of bowel. LVN C stated Resident # 1 fell on [DATE] at 6:45 AM. She stated Resident # 1 was on the floor bleeding from his head and had blood on his hand. The LVN stated there was blood everywhere on the floor. She applied a pressure dressing to the resident's forehead. She and CNA N stood the resident up and walked him to his bed. The LVN took vital signs and conducted a neurocheck. Resident # 1 was alert and answering questions. He wanted to smoke. The LVN told him that they were going to take him to breakfast and that smoking was at 9:00 AM. Resident #1 was taken to the dining room for breakfast, but he did not eat much. Interview with CNA N on 05/04/18 at 11:56 AM revealed on 04/30/18 at 6:45 AM, she heard Resident #1 yelling for help. She stated she found Resident #1 lying on his side on the floor in his room and went to get the licensed nurse. The nurse aide stated the resident was bleeding from his forehead. The licensed nurse and CNA N returned to the room. The licensed nurse told her to stay with the resident while she went to go get another nurse. Both nurses returned to the room with the treatment cart. Resident # 1 stated, I smashed my head really hard. I need to go to the hospital. RN G told the resident he did not need to go to the hospital because he did not need stitches. CNA N stated she cleaned up the resident. LVN C and CNA N picked up Resident # 1 off the floor and put him in the wheelchair. Interview with LVN C on 05/01/18 at 2:02 PM revealed that on 04/30/18 after breakfast, a nurse aide took Resident #1 to smoke. The resident appeared confused and tried to put the lit end of the cigarette into his mouth. The resident was returned to his room and placed into bed. She stated she watched him closely. She stated about an hour after the resident smoked a cigarette at 9:00 AM, she found him on the floor. The resident stated he was trying to get back into bed. Resident # 1 stated his legs were hurting. LVN C picked up the resident off the floor and put the resident back into bed. The nurse aide got him up for lunch. Review of the nurses' notes revealed no nursing documentation of a nursing assessment, vital signs, neurochecks, and no physician notification of the fall. Review revealed no incident report documentation of the fall on 04/30/18 at around 10:00AM. Further review of the nurses' note revealed LVN C documented on 04/30/18 at 1:00 PM, that Resident #1 requested coffee and poured coffee onto the floor in his room and in the dining room. Resident #1 wanted to be assisted back to bed and then putting himself on floor and yelling for help, assisted to w/c (sic wheelchair) multiple times and wheeled to nurses' station. Resident #1 would wheel self-back to his room and yell for help to be assisted back to bed. Resident was up to the dining room and was served coffee by a staff member. LVN C documented that a staff member stepped out of the dining room to assist another resident. Resident #1 poured coffee onto the floor and then sat self on floor. Another resident picked up Resident #1 off the floor. Staff took Resident #1 to his room. There was no documentation of vital signs or a nursing assessment. The physician was notified and a new order for [MEDICATION NAME] (antipsychotic medication) 2 mg twice a day was obtained. Interview with CNA N on 05/04/18 at 11:56 AM revealed that on 04/30/18, she heard Resident #1 yelling for help. She entered the resident's room and found him on the floor. She called for the nurse and the nurse came and assessed the resident. The nurse and CNA N put the resident in his wheelchair and she took him to the dining room. She stated RA A was in the dining room serving soup and drinks to the residents. CNA N said she left the dining room with RA A and that no other staff was in the dining room. She stated when they returned to the dining room Resident #7 told them that Resident #1 had fallen out of his wheelchair. Resident #7 stated he had picked the resident up and put him back in his wheelchair. RA A went and notified a nurse who came and took the resident out of the dining room. She stated the Administrator returned the resident to the dining room and attempted to feed the resident. Interview with Dietary Staff O on 05/04/18 at 9:00 AM revealed she was getting ready to serve lunch when she heard a sound coming out of the dining room. She stated she went to see what happened and saw Resident #7 picking up Resident #1, who was lying on the floor. Dietary Staff O saw Resident #7 sit Resident #1 into his wheelchair. Dietary Staff O saw two physical therapy staff enter the dining room, but the resident was already in the wheelchair. The Dietary Staff O did not inform the charge nurse. Interview with Resident # 7 on 05/04/18 at 1:17PM confirmed he saw Resident #1 fall out of his wheelchair. Resident #7 stated there were no staff in the dining room, so he decided to pick up the fallen resident off the floor. Resident #7 stated he picked up Resident #1 by his shoulders. Resident #7 stated he told the nurse when she came back to the dining room. Interview with ADON L on 05/01/18 at 3:23 PM revealed on 04/30/18, the kitchen staff wheeled Resident #1 to the nurses' station around lunch time. The kitchen staff stated another resident picked up Resident #1 off the floor in the dining room. The ADON L stated she should have directed kitchen staff to tell a nurse. The ADON did not inform the resident's nurse. The ADON L did not further investigate the fall in the dining room. Interview with PTA M on 05/05/18 at 9:53 AM revealed on 04/30/18, he was in the therapy gym when a nurse aide asked him to help pick up Resident #1 on the floor in the dining room. PTA M stated when he entered the dining room, Resident #7 had already picked up Resident #1 and he was sitting in a wheelchair. PTA M stated he left the dining room and went back to the therapy gym. He stated he did not take the resident to a nurse nor did he tell a nurse what happened. Interview with RA A on 05/08/18 at 2:56 PM revealed she was serving soup and drinks to the residents in the dining room on 04/30/18 at lunch time. She stated she left the residents unattended so that she could help another CNA with resident care. She stated when she returned to the dining room, she learned that Resident #1 fell on to the floor and another resident picked him up. She stated she did not notify the nurse that Resident #1 fell . Interview with LVN C on 05/01/18 at 2:02 PM revealed Resident # 1 fell at 2:00 PM on 04/30/18. The resident stated he wanted to use the urinal. Review of Resident #1's record provided no evidence of a nursing assessment, neurocheck or physician notification of the fall on 04/30/18 at 2:00 PM. Review of the nurses' note by LVN C dated and timed 04/30/18 at 5:26 PM revealed Resident #1 was found on the floor in his room and yelling out for help. LVN C documented the resident was bleeding from his mid forehead and both arms and both legs were covered with blood. LVN C stated the resident was using bed linens to wipe his forehead. Resident # 1 stated he was looking for his wheelchair. LVN C completed neurochecks and notified the physician. There was no documentation of a head to toe nursing assessment, pain/fall assessment or vital signs. There was no incident report. The physician was not notified. Review of the nurses' note by LVN D dated and timed 04/30/18 at 5:52 PM revealed Resident #1 was anxious and wanted to get up and smoke but was redirected to stay in bed due to continues (sic) falls and for his safety. Resident # 1 yelled and screamed that he wanted to get out of bed to smoke. The resident was found on the floor mat next to his bed at 5:00 PM. LVN D documented Resident #1 was on his knees looking for his shoes. LVN D redirected the resident and told him he could not go outside. The LVN documented that he was given one to one care and was able to stay in bed. LVN D documented resident was caught getting up out of bed and was redirected to stay in bed. Resident # 1 was still anxious, watched over, will monitor for changes. Vital signs were: Temperature 98, Pulse 106, Respirations 18 and blood pressure 136/70. There was no documentation of neurocheck, pain assessment, and head to toes assessment or fall risk assessment. The physician was not notified. Interview with CNA F on 05/04/18 at 2:00 PM revealed she was assigned to Resident #1 on 04/30/18 on the evening shift. She stated she received report that Resident #1 had multiple falls during the morning shift. CNA F stated she heard Resident #1 yelling and when she went to the room, she saw Resident # 1 on the lying on his side on the floor. She stated LVN D, a medication aide and her picked up the resident off the floor. CNA F stated around 4:00 PM she heard a noise coming from the room of Resident # 1. She saw the wheel chair was towards the bathroom and she found Resident #1 lying on the floor on his left side with his left leg bent and his right leg straight. CNA F and LVN D picked the resident up and put him into bed. CNA F stated Resident #1 fell around 5:30 PM, but she did not help since she was serving in the dining room. CNA F stated at around 7:30 PM, she heard a noise, went into the room of Resident #1 and saw him lying on the floor on his right side. CNA F stated three staff picked up the resident off the floor. She stated the resident was crying in pain. Further review of Resident #1's nurse's note, dated 05/01/18, reflected the DON noted on 10:05 AM, When entered the building at 8am noticed bed in hallway. Administrator and state investigator met me at the door Spoke with administrator as to why the bed was in the hall. Admin reported resident had a fall and some behavior issues on Monday and the mattress was placed on the floor . 1020 Went to resident in hall and noted bruising to face and trunk as well as arms. Resident c/o (sic complained of) pain to r (sic right) side and hip. At that time instructed to send him to ER for evaluation and to notify Dr Review of the SBAR Communication Form and progress note dated 05/01/18 at 11:09 AM written by LVN C revealed Resident #1 had a compression dressing to his forehead with multiple bruising to both arms and legs and torso with multiple sizes and colors . decrease consciousness, needs more assistance with ADLS, slurred speech, fall, abnormal lung sounds . bruises to right eye brow and right cheek bone, red bruise to left hip. Review of a late entry nurse's note, completed by LVN C on 05/01/18 at 3:37 PM, revealed, (Resident #1) with purple bruise to right brow, cheek bone, red 10 cm x 2 cm bruise to left hip . lethargic with slurred speech at time, yelling for help. Resident uncomfortable in bed and wheelchair, vital signs, 110/72- 88-20-98.5 sat 94%. LVN C notified the physician and obtained an order for [REDACTED].#1 was transferred to the emergency room at 12:10 pm on 05/01/18. Note: This was 1 hour and 50 minutes after the DON instructed staff to send Resident #1 to a local hospital for evaluation. Interview with LVN C on 05/01/18 at 2:02 PM revealed on 05/01/18 at around 7:00 AM she noted a bruise to the right brow extended to the cheek of Resident # 1. The resident was lethargic with slurred speech. The resident could not open his eyes and was mumbling. LVN C stated at around 9:00 AM (two hours later), she called the doctor to send the resident to the hospital and got an order for [REDACTED]. Interview with the DON on 05/05/18 revealed she was not notified about the falls. There were no incident reports for all the falls. She stated she expected a head to toe assessment, fall risk assessment, pain assessment after a fall. The DON stated Resident #1 had a change in condition that required emergent medical interventions. Review of Resident #1's hospital record revealed the CT scan of the head, dated 05/02/18, revealed .suspect small subdural hematoma new from prior study . The CT scan of the abdomen and pelvis, dated 05/02/18, revealed a left [MEDICAL CONDITION]. A chest x-ray, dated 05/02/18, revealed . multiple right sided rib fractures with a small right sided pneumothorax (lung collapse). Review of a Physician Consultation note, dated 05/01/18, from the trauma hospital revealed Resident # 1 was transferred from a local hospital for trauma and neurosurgical services. The physician documented that Resident # 1 had multiple falls, which resulted in altered mental status. The resident was admitted to the intensive care unit. Interview with the DON on 05/08/18 at 4:10 PM revealed she was not in the building on 04/30/18 when Resident #1 had multiple falls. Review of the undated policy Incident/Accident System revealed 3. Complete a fall investigation report after every fall. A head to toes assessment must be completed at the time of the incident .9. All residents are at risk for falls. An assessment will be conducted on admission and the findings of the assessment will be included in the plan of care. 10. A fall prevention program will be initiated. The program will be reviewed with any subsequent falls. All programs will be documented in the plan of care and updated with each new fall. 11 .B . a resident fond on floor is considered to have fallen. Review of the policy Charting and Documentation dated (MONTH) 2008 revealed .3. All incidents, accidents, or changes in the resident's conditions must be recorded . The Administrator and DON was notified on 05/04/18 at 5:38 PM that an Immediate Jeopardy was identified, and a plan of removal was requested at that time. The Plan of Removal reflected: --Education would be provided on abuse/neglect, fall prevention, what to do when a resident falls, staff responsibility to ensure that interventions are in place as ordered, completing a post fall care plan, how to complete a post fall physical assessment, change in condition and pain assessment; and --Audit of incident reports for last 30 days to determine residents with multiple falls, and care plan updates. --The plan of removal will be completed by 05/07/18 at 10:00 PM Interviews on 05/08/18 from 1:54 PM to 4:03 PM from all shifts revealed 3 of 3 LVNS (LVNs C, D, L), 1 of 1 RN (RN G) and 4 of 4 CNAs (RA A, CNA F, L K) revealed they had received in-service training on neglect and what to do when a resident fall, change of condition and pain assessment. Incident reports for the last 30 days were audited, fall risk assessments and care plans were updated. Resident #1 identified in the Immediate Jeopardy (IJ) was discharged from the facility on 5/01/18. The IJ was removed on 05/08/18. Although the IJ was removed, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of isolated because the facility was still monitoring the Plan of Removal. The facility form Incident by Date for (MONTH) (YEAR), dated 05/08/18, revealed 21 residents fell in the month of April.

Based on observation, interview, and record review, it was determined the facility failed to care for its residents in manner and in an environment that promotes maintenance or enhancement of each resident's quality of life for one (Resident #1) of 17 residents reviewed for quality of life. 1) Resident #1 reported feeling degraded and worthless by statements made by the facility Administrator. 2) A confidential group of 16 residents petitioned that Resident #1 was, "bullying residents and staff", and being "bossy." 3) Confidential interviews confirmed inappropriate comments made by staff to Resident #1, which made him "feel like crap," "degraded" and "worthless." 4) The resident had received two previous 30-Day Discharge Letters, which were overturned on appeal and a third 30-Day Discharge Letter sent to the resident was currently pending a third appeal. These failures caused Resident #1 to feel degraded, and worthless, which had the potential to affect all 79 residents in the facility, placing them at risk for a decreased quality of life due to the potential of staff treating the residents without providing and environment, which promotes the resident's quality of life. Findings included: Review of the MDS assessment dated [DATE] revealed Resident #1 was 45-years-old and was admitted on [DATE] with [DIAGNOSES REDACTED]. The assessment reflected Resident #1 was oriented, alert, interviewable and his memory was intact. The assessment also reflected he exhibited no signs of [MEDICAL CONDITION], disorganized thinking or psychomotor [MEDICAL CONDITION], but had exhibited verbal behavioral symptoms directed at others and frequently rejected care. Interview conducted with Resident #1 at 12:45 p.m. on [DATE] revealed the Administrator said to him, "You're on Medicaid. I pay taxes...so we pay for your room...." Resident #1 stated this comment, "...made me feel like crap." Resident #1 stated, "...(Staff) screamed at me that other people here don't like me, other patients here like me and I like them." Resident #1 stated the Administrator, "...called me into his office the other day and asked me why I was talking to this little lady here, 'botherin' her...pressing her for information about my uncle who died here and was left in the room on the floor...I never even went to her room...I felt degraded, worthless." Review of the Care Plan dated [DATE] for Resident #1 revealed a problem of, "Resident verbally disruptive, becomes agitated & verbally hollers & curses staff. Gets in staff's face. Argumentative with staff intimidating due to Personality Disorder." Also identified was a problem of, "I display socially inappropriate/disruptive behavior, explosive, multiple complaints over everything due to Personality Disorder." Review of the Nurse's Notes dated [DATE] through [DATE] for Resident #1 revealed 39 instances of refusal of sliding scale insulin, refusal to go to the hospital four times, and eight verbal confrontations with staff. There were no documented altercations with residents or physically aggressive behaviors towards residents and/or staff in the clinical record. Review of the Accident/Incident Reports for the past three months ([DATE] through [DATE]) revealed no physical harm or verbal threats documented involving Resident #1. A confidential staff interview revealed staff did not always explain issues thoroughly enough for Resident #1 to understand. The staff member stated some staff, "just walk away from him" when Resident #1 wanted something explained. This staff member stated Resident #1 then, "follows staff for explanation." The staff member stated currently Resident #1, "does not talk to residents and has been shunned by staff and residents." The staff member stated he/she has never observed Resident #1 being violent, but Resident #1 was observed helping other residents by getting more drinks or requesting/obtaining more food and was always the last resident to be served in the dining room. This staff member stated he/she saw that the Administrator and many other staff members "won't even speak to Resident #1 and don't treat him like a human." Another confidential staff interview revealed Resident #1, "has problems, medical and mental...but has observed other staff 'antagonizing him (Resident #1)...pushed to set him off." This staff member stated he has heard a specific staff member saying to Resident #1, "I have nothing to say to you...I will not talk to you." In this interview, the staff member stated all staff have been instructed by Administration to call 911 if Resident #1 raised his voice and these instructions have been heard, "during staff inservices conducted at the Nurse's Station in the middle of the facility with visitors and residents within hearing distance." This staff member stated he/she witnessed Resident #1 talking to a staff member about his (Resident #1's) check missing. This staff member stated Resident #1 did not raise his voice, but the staff member called the Administrator back to the facility. This witness observed the Administrator return to the facility, entering with a raised voice, "chest out, in a threatening posture confirming that 'if he'd (the Administrator) come up to me (staff member) like that, I'd (staff member) feel threatened.'" Another incident was described by this staff member, "...(Resident #1) normally uses the resident phone. All residents get phone calls at the Nurses Station and stand by or at the Nurses Station to talk on the phone. When Resident #1 received a call at the station, another staff member was observed to interrupt the call to tell him (Resident #1) he could not use that phone. Later that day in the dining room full of staff and residents, the Administrator confronted Resident #1 and told him he (Resident #1) was not allowed to be anywhere around the Nurse's Station. Resident #1 was heard to, "ask to make sure" and the Administrator repeated himself, "in front of other residents." This staff member also overheard another staff member say to Resident #1, "I can no longer talk to you." The Administrator was then heard to say, "I don't blame... for saying that if someone spit and accused me, I'd do the same." This was in reference to an incident on [DATE] in which an LVN was suspended and subsequently terminated when the LVN loudly said (in front of staff and residents) to Resident #1, "Get the F--- out of my face." Review of the 30-Day Discharge Letters issued to Resident #1 revealed the first one was dated [DATE] by the previous Administrator and reflected, "safety of individuals in the facility is endangered." Another letter dated [DATE] reflected "the safety of individuals in the facility is endangered." The third letter dated [DATE] reflected, "...resident needs cannot be met...the safety of individuals is endangered...health of individuals in the facility would otherwise be endangered." This notice was appealed by Resident #1 as the facility had not followed guidelines, and the hearing was postponed until [DATE]. Confidential interview revealed an observation made of an administrative staff member aggressively asking Resident #1 why he was not more upset over not getting his check for the month stating, "Why aren't you upset or raving about it?" According to the witness, the administrative staff member sounded accusatory. Resident #1 was upset but had not gotten loud at that point, but the administrative staff member called the Administrator anyway. The next day checks were found, but Resident #1's was not included. The Administrator said to Resident #1 that he was going to have all the checks fingerprinted by the federal Post Office and had checks placed in a plastic bag. This witness also witnessed the Administrator's description of the incident of him telling Resident #1 he paid taxes for Medicaid, and then asked another staff if they paid taxes and therefore, he (the Administrator) was paying for Resident #1 to be here. This witness also heard, "almost every weekend, the Administrator says, "if you have any problems with (Resident #1), call 911." This witness verified staff meetings were occurring at the Nurse's Station and residents were mentioned in such detail that everyone knew who the resident was. This witness also stated he/she had heard the Administrator to say, "If appeal is upheld I will just do it again." (Regarding the 30-day discharge notice to Resident #1.) This witness stated at one point during the appeal of the 30 Day Notice given to Resident #1, Resident #1 was observed to ask for copies of the paperwork and the Administrator was overheard saying it would cost the resident 25 cents per page. This witness also verified hearing the Administrator tell Resident #1 he (the Administrator) paid taxes, which paid for the resident's room at the facility. On [DATE] at 1:30 p.m. a confidential group interview was conducted with 16 residents, who the facility identified as alert and interviewable, the facility Social Worker, and the Regional Ombudsman. The residents had written and signed a petition to have Resident #1 removed from the facility. Complaints by the residents were global and nonspecific revealing many residents believed Resident #1 was a, "bully," "rude," and "threatening in his facial expressions." However, no resident stated they had witnessed any physical harm by Resident #1 and denied verbal threats of harm were witnessed or heard toward other residents by Resident #1. All the residents were aware of police being called to the facility and believed Resident #1 had to be bad "cause the police were called to talk to him." An interview conducted at 3:00 p.m. on [DATE] with the Administrator revealed that he believed Resident #1 was endangering residents due to his, "threatening facial expressions." The Administrator also stated that Resident #1 had made threats against him and his family. Resident #1 was identified by the Administrator as a "felon" and therefore a threat. The Administrator stated the felony was for drugs and believed the resident bought and sold illegal drugs. Therefore, the Administrator felt Resident #1 had connections to people who could hurt or kill anyone chosen. Interviews conducted on [DATE], [DATE], and [DATE] with the Regional Ombudsman and facility Social Worker revealed efforts had been made for finding a more appropriate placement for Resident #1 and have continued as documented in Social Service Notes and by the Regional Ombudsman. The Social Worker stated now Resident #1 had some more options made available to him through CBA Programs, but he must continue the process and had no other housing options at this time. Review of the Resident Roster dated [DATE] revealed a total census of 79.