Every finding on record at Focused Care of Center

Based on observation, interview, and record review the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relayed the call directly to a staff member or to a centralized staff work area from toilet and bathing facilities for 3 of 20 residents (Resident #45, Resident #17, and Resident #41) reviewed for call lights.The facility failed to ensure Resident #17's emergency call light string in the bathroom would reach the floor as it was approximately four feet above the floor on 8/10/2026.The facility failed to ensure Resident #41's emergency call light string in the bathroom would reach the floor as it was approximately two feet above the floor on 8/10/2026.The facility failed to ensure Resident #45's emergency call light string in the bathroom would reach the floor. The call light cord for Resident #45 was two 1/2 feet above the floor on 8/10/2026.These failures could place residents at risk of injury, pain, hospitalization, and a diminished quality of life. Findings included: 1.Record review of an admission Record for Resident #45 dated 8/11/2026 indicated he admitted to the facility on [DATE] and he was [AGE] years old with muscle weakness, lack of coordination, and dementia (confusion). Record review of a Quarterly MDS Assessment for Resident #45 dated 5/29/2026 indicated he had intact cognition with a BIMS score of 12. He required set up assistance with personal hygiene, intermittently required assistance with toilet hygiene and required use of a cane with walking. Record review of a care plan for Resident #45 dated 11/21/2024 indicated he was at risk for falls related to impaired mobility. Interventions included to be sure call light was within reach and encourage resident to use it for assistance as needed. During an observation on 8/10/2026 at 10:00 am, Resident #45 was in his room. The call light string was two 1/2 feet above the floor. During an observation on 8/10/2026 at 11:00 am, Resident #45 was walking down the hallway. He said she was able to go to the bathroom on his own. During an observation and interview on 8/10/2026 at 11:30 am, CNA A said Resident #45 was assigned to her that day. She observed the call light that was two 1/2 feet above the floor and said Resident #45 would not be able to reach it if he had a fall in the bathroom and would not be able to call for help. She said all staff were responsible for checking the call light strings to ensure they were long enough to reach the floor. 2. Record review of an admission Record for Resident #17 dated 8/11/2026 indicated she was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia (a decline in thinking that can interfere with daily life), hypertension, (high blood pressure) and depression (sadness or loss of interest in doing things). Record review of a Quarterly MDS Assessment for Resident #17 dated 6/3/2026 indicated she had moderate impairment in thinking with a BIMS score of 7. She required partial/moderate assistance with toileting hygiene and required supervision or touching assistance with walking. Record review of a care plan for Resident #17 dated 3/4/2026 and revised on 3/7/2026 indicated he had poor safety awareness and may need as needed moderate assist with transfer due to weakness. Interventions included ensuring call light was in reach and answer promptly. During an observation and interview on 8/10/2026 at 9:39 AM, Resident #17 was lying on her bed. She said she had been at the facility for about five to six months. The call light string in the bathroom was short, approximately four feet above the floor. She said she used the bathroom on her own. 3. Record review of an admission Record for Resident #41 dated 8/11/2026 indicated she was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of COPD (a group of lung disease that affect breathing), type 2 diabetes, hypertension, (high blood pressure) and major depressive disorder (persistent sadness or loss of interest in doing things). Record review of a Quarterly MDS Assessment for Resident #41 dated 5/22/2026 indicated she had moderate impairment in thinking with a BIMS score of 12. She required partial/moderate assistance with toileting hygiene and required supervision or touching assistance with walking. Record review of a care plan for Resident #41 revised 3/1/2026 indicated she had a history of falls. Interventions included ensuring call light was in reach. During an interview on 8/10/2026 at 9:31 am, Resident #41 was lying in bed. She said she had been at the facility for two 1/2 years and was able to go the bathroom on her own. She said she never noticed the call light string in the bathroom being too short. The call light string was approximately two feet above the floor. During an interview on 8/10/2026 at 4:00 PM, the Administrator said all staff were responsible for checking the call lights daily to ensure they were in reach. She said residents could be at risk of being on the floor for a long time if they needed help and could not reach the string. During an interview on 8/11/2026 at 11:00 am, the DON said all staff were responsible for checking to make sure call lights were in reach. She said the call light should hang long enough so if a resident fell, they would be able to reach it. She said there could be a delayed response for the staff to find if a resident was not able to reach the string to call for help. Record review of a facility policy titled Quality of Life-Accommodation of Needs revised August 2009 indicated, .Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being. 3. In order to accommodate individual needs and preferences, adaptions may be made; e. installing longer cords so that they are easily accessible .

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 1 of 10 residents (Resident #5) reviewed for safe transfers.The facility failed to ensure CNA C used a mechanical lift to transfer Resident #5 on 8/11/2026.This failure could place residents at risk of falls or injuries.Findings included:Record review of an admission Record for Resident #5 dated 8/11/2026 indicated he was admitted to the facility on [DATE] and he was [AGE] years old with diagnoses of cerebral palsy (a group of permanent movement disorders that appear in early childhood), BPH (enlarged prostate), and hypertension (high blood pressure).Record review of a Quarterly MDS Assessment for Resident #5 dated 7/31/2026 indicated he had severe impairment in thinking with a BIMS score of 4. He required substantial/maximal assistance with toileting hygiene, and he used a wheelchair for mobility. Record review of a care plan for Resident #5 dated 1/29/2026 indicated he had a history of falls with interventions that were initiated on 5/28/2026 for a mechanical lift for all transfers to wheelchairs.Record review of a POC Task for Resident #5 undated indicated he required a mechanical lift for transfers every shift.Record review of a list of residents who required a sling/mechanical lift for transfers undated indicated Resident #5 was on the list.During an observation on 8/11/2026 at 1:20 pm, CNA C was in the room of Resident #5 to provide incontinent care. Resident #5 was sitting on a lift sling in a specialized wheelchair. CNA C placed gloves on her hands and positioned the wheelchair by the bed and pulled the linens back. CNA C grabbed Resident #5 around his upper back and interlocked her fingers and lifted him out of his chair and transferred him to the bed. After care was provided CNA C positioned Resident #5 to sit on the side of the bed and transferred him back to his wheelchair wrapping her arms around his upper back. During an interview on 8/11/2026 at 1:38 pm, CNA C said she had been employed for a month. She said she was a new nurse aide. She said she had a skills check off during orientation on using mechanical lifts. She said she did not use a lift for Resident #5 because she felt comfortable with transferring him without assistance and never used the mechanical lift on him but other staff did. Record review of a mechanical lift transfer competency evaluation for CNA C dated 7/7/2026 indicated she demonstrated using a lift for transfers.During an interview on 8/12/2026 at 9:36 a.m., the DON said Resident #5 required a mechanical lift for all transfers. She said the nurse aides could see in their POC what kind of transfers residents required. She said staff were trained in how to use a mechanical lift during their yearly evaluations with competency skills check offs and on hire. She said if staff did not use the appropriate technique for transfers a resident could be at risk for injury. She said all staff had access to the POC for each resident so they would be able to see who required a mechanical lift for transfers.The Administrator was unavailable for an interview on 8/12/2026.Record review of a facility policy titled Safe Lifting and Movement of Residents revised July 2017 indicated, .In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. 2. Manual lifting of residents shall be eliminated when feasible. 5/ Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary .

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #16 and Resident #5) reviewed for infection control.The facility failed to ensure CNA B washed or sanitized her hands or changed gloves while performing incontinent care for Resident #16 on 8/10/2026.The facility failed to ensure CNA C washed or sanitized her hands, change gloves, did not place dirty linens on the floor, and clean the resident properly when incontinent care was provided to Resident #5 on 8/11/2026.These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: 1.Record review of an electronic face sheet for Resident #16 indicated she was a [AGE] year-old female that admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease (progressive brain disorder that slowly destroys memory, thinking skills), morbid obesity (having a Body Mass Index of 40 or higher), and muscle weakness. Record review of Resident #16's Quarterly MDS dated [DATE] indicated Resident #16's BIMS score was not completed because Resident #16 was rarely or never understood. Resident #16 was dependent for toileting hygiene. Record review of Resident #16's care plan dated 11/14/2024 indicated: I have ADL self-care performance deficits related to disease processes. I need substantial assist to moderate assist for ADLs due to weakness, incontinence, and cognitive deficits. I feed myself at times and need a wheelchair for locomotion with interventions that included: The resident requires substantial assistance by 1 staff with personal hygiene and oral care. and The resident requires substantial assistance by 1 staff for toileting. During an observation on 08/10/2026 at 9:45 AM, Resident #16's incontinent care was provided by CNA B and CNA A. CNA B provided the majority of the care with CNA A helped to turn Resident #16. After cleaning Resident #16 from front to back CNA B rolled Resident #16 onto her right side and CNA B changed gloves but did not wash or sanitize hands before donning new gloves. CNA B then cleaned bowel movement from Resident #16, placed a new brief on Resident #16 and repositioned clothing, she did not change gloves, wash or sanitize hands. CNA B then removed the gloves and did not wash or sanitize hands and transferred Resident #16 via mechanical lift to her wheelchair. During an interview on 08/10/2026 at 10:01 AM, CNA B said she had worked at the facility for 6 months and had been a CNA for 1 year. She said during incontinent care she forgot to switch out her gloves at the very end. She said she did not wash or sanitize her hands during the incontinent care because she forgot to bring sanitizer with her. She said she should have sanitized her hands in between each glove change. She said it could cause the residents to get an infection by not sanitizing or washing her hands. During an interview on 08/10/2026 at 10:13 AM, CNA A said she had been a CNA for 2 years. She said CNA B did not wash or sanitize her hands in between glove changes. She said by not sanitizing or washing their hands they could spread germs and infection from resident to resident. Record review of CNA competency evaluation for peri/incontinent care, female (without catheter) dated 2/9/2026 for CNA B indicated she had met expectations. Record review of CNA competency evaluation for peri/incontinent care, female (without catheter) dated 1/29/2026 for CNA A indicated she had met expectations. Record review of CNA competency evaluation for peri/incontinent care, female (without catheter) dated 4/30/2026 for CNA A indicated she had met expectations. 2. Record review of an admission Record for Resident #5 dated 8/11/2026 indicated he was admitted to the facility on [DATE] and he was [AGE] years old with diagnoses of cerebral palsy (a group of permanent movement disorders that appear in early childhood), BPH (enlarged prostate) and hypertension (high blood pressure). Record review of a Quarterly MDS Assessment for Resident #5 dated 7/31/2026 indicated he had severe impairment in thinking with a BIMS score of 3. He required substantial/maximal assistance with toileting hygiene. He was always incontinent of urine/bowel. Record review of a care plan for Resident #5 dated 1/29/2026 indicated he had an ADL self-care performance deficit related to disease process and was incontinent of bladder and bowel. Interventions included he required substantial assistance by one staff with personal hygiene. During an observation on 8/11/2026 at 1:20 pm, CNA C was in the room of Resident #5 to perform incontinent care. CNA C placed gloves on her hands without washing or sanitizing them. Resident #5 was in bed, and CNA C removed his shoes and placed them in his wheelchair and removed his pants and placed them on the floor. She opened his brief and pulled it down between his thighs and sprayed perineal cleanser to his groin area. She removed wipes from a package and wiped his groin area down both inner thighs and placed the wipes in the trash. She removed more wipes and cleaned his penis in a circular motion and Resident #5 was uncircumcised. She rolled the brief under his buttocks and rolled him onto his left side and removed the brief and placed it in the trash. She opened his drawer, removed a clean brief, placed it under the resident buttocks, removed more wipes, wiped his rectal area from front to back and placed the wipes in the trash. She positioned the brief under his buttocks and had the resident roll onto his right side and then onto his back and secured the brief. She opened his closet and removed a pair of pants after touching multiple clothing items in the closet with the dirty gloves. She placed the pants on the resident and put his shoes back on. The resident was positioned to sit on the side of the bed and transferred back to his wheelchair. She handed him a ball, gloves, and cup that were on his dresser. She removed her gloves and placed them in the trash and did not wash or sanitize her hands after glove removal. She opened his personal refrigerator and handed him a drink. She removed the under pad from the bed and placed it on the floor and straightened the bed. She removed the trash, tied it, and took it to the soiled linen closet down the hall and placed it in the trash. She did not wash her hands after placing the bag in the trash and removed a pillowcase from the linen cart in the hallway and reentered the room and picked up the dirty linens from the floor with her bare hands and took them to the dirty linen closet down the hall. She exited the dirty linen closet and sanitized her hands. During an interview on 8/11/2026 at 1:38 pm, CNA C said she had been employed at the facility for a month and was a new nurse aide. She said she had a skills check-off during her orientation that included incontinent care. She said she was not taught that she had to change gloves during incontinent care. She said she did not wash or sanitize her hands before care was started. She said dirty linens should not be placed on the floor and had not been taught anything different. She said she should not have touched clean items with dirty gloves. She said she was not sure about when to change gloves or when hand hygiene should be performed during care. She said for an uncircumcised male she should have pulled his skin back and clean. She said bacteria and infections could occur to residents if she did not follow proper procedures. Record review of a nursing services competency evaluation for CNA C dated 7/7/2026 indicated she was observed performing incontinent care with a male resident without a catheter and she met expectations. During an interview on 8/12/2026 at 9:36 am, the DON said she was the IP for the facility and staff were trained on infection control quarterly that included hand hygiene. She said the facility did not have one person assigned to train new staff. She said hand hygiene should be performed before care, before gloves were applied, after care was completed, and between residents that could include hand washing or use of a sanitizer. She said staff should have as many gloves as possible in the room when care was provided. She said gloves should be changed when changing tasks going from dirty items to clean items. She said soiled linens should be placed in a plastic bag and not on the floor. She said staff should never touch clean items with dirty gloves. She said gloves should be removed when tasks were changed and hand hygiene performed. She said when incontinent care was provided to a male resident who was uncircumcised the staff should pull foreskin back and clean in a circular motion and then place the skin back. She said residents could be at risk of infections if staff did not follow proper procedures. The Administrator was not available for interview on 8/12/2026. Record review of a facility policy titled Perineal Care dated 10/1/2021 indicated, .To provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Steps in the procedure: 2. Wash and dry your hands. 6. put on gloves. 9. For a male resident: b. 1. retract foreskin of the uncircumcised male. 2. clean the urethral area using a circular motion. 3. continue to wash the perineal area including the penis, scrotum, and inner thighs. d. reposition foreskin of uncircumcised male. 11. remove gloves and discard into designated container. Wash and dry your hands thoroughly . Record review of a facility policy titled Hand Hygiene revised 10/24/2022 indicated, . Hand hygiene is used to prevent the spread of pathogens in healthcare settings. 1. You should always perform hand hygiene; before applying and after removing personal protective equipment (e.g., gloves); before and after providing any type of care; after contact with medical equipment or other environmental surfaces that may be contaminated. 2. You must perform hand hygiene after contact with bodily fluids . Record review of a facility policy titled Laundry and Bedding, Soiled revised October 2018 indicated, .Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control. Handling: 1. All used laundry is handled as potentially contaminated until it is properly bagged and labeled for appropriate processing. b. Laundry that is contaminated with blood or body substances is placed in leak-proof bags, or containers .

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety requirements and kitchen sanitation. The facility failed to ensure the ice machine was properly cleaned on 8/10/2026 at 9:30 AM. The facility failed to ensure the water filter for the ice machine was clean on 8/10/2026 at 9:30 AM. These failures could place residents who eat from the kitchen at risk of foodborne illnesses. Findings include: During an observation on 08/10/2026 at 9:30 AM, the ice machine located in the dining area had black and brown substance on the white plastic water curtain guard located in the ice machine above the ice. The water filter located behind the machine was dark brown in color. During an interview with the dietary manager on 8/10/2026 at 9:35 AM, she stated the facility maintenance supervisor was responsible for changing the water filters and cleaning the ice machine. She stated she was not sure of the cleaning timeframe or when the ice machine was last cleaned. She stated she did not know how often the water filter was changed. During an interview with the administrator on 8/10/2026 at 10:00 AM, she stated the facility maintenance supervisor was responsible for maintaining the water filter for the ice machine and cleaning the ice machine. She stated she believed it had been checked and cleaned in the last week. She said she would have to ask the maintenance director for the cleaning schedule and when the filters were last changed. During an interview with the maintenance supervisor on 8/12/2026 at 10:00 AM, he stated he had been at the facility for over a year. He stated he was responsible for cleaning and maintaining the ice machine. He stated he changed the water filter to the ice machine monthly and as needed. He said he visually inspects the filter weekly. He stated there had been water issues with the city requiring him to change the filter more frequently. He stated he last inspected the filter last week (week of 08/02/2026). He said he had deep cleaned the ice machine in July 2026. He said he cleans the machine quarterly and as needed. He said that he may have missed that small section of the guard located in the ice machine that had the dark substance on it. He said he maintains a log book for all his maintenance tasks. He said not having a clean water filter and regular cleaning of the ice machine puts residents at risk for consuming contaminated ice and cause the ice machine to not work properly. Administrator not available for follow up interview on 8/12/2026. Record review of a facility policy titled Ice Machines and Ice Storage Chests revised September 2005 indicated, 3. Our facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacture's instructions. Record review of Manitowoc service manual dated May 2005 indicated in section 4-3 Clean and sanitize the ice machine every six months for efficient operation. If the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment.

Based on interview and record review the facility failed to ensure the right to be free from misappropriation of resident property for 5 of 10 residents (Resident #1, Resident #5, Resident #6, Resident #8, and Resident #12) reviewed for misappropriation of resident property.The facility failed to ensure the [NAME] did not use Resident #1, #5, #6, #8, and #12's food debit card for personal use on 6/28/2025, 7/26/2025, 8/26/2025, and 8/31/2025.This failure could place residents at risk for decreased quality of life, misappropriation, and dignity.Findings include:1.Record review of a facility admission record for Resident #1 dated 10/6/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia (occurs when the brain nerve cells die), type 2 diabetes, major depressive disorder (persistent sadness and loss of interest in doing things), and heart failure. She was discharged from the facility on 9/19/2025.Record review of a Quarterly MDS Assessment for Resident #1 dated 9/12/2025 indicated she did not have any impairment in thinking with a BIMS score of 14. She was independent with activities of daily living except for toileting hygiene and shower/bathing when she needed setup or clean-up assistance.Record review of a care plan for Resident #1 dated 4/21/2025 indicated she had impaired cognitive function or impaired thought processes. Interventions included to keep the routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion.2. Record review of a facility admission record for Resident #6 dated 10/7/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of major depressive disorder, dementia, hypertension, and osteoarthritis (stiffness, joint pain). She was discharged on 10/3/2025 to the hospital.Record review of a Quarterly MDS Assessment for Resident #6 dated 9/24/2025 indicated she had moderate impairment in thinking with a BIMS score of 9. She required supervision with eating, oral and toileting hygiene.Record review of a care plan for Resident #6 dated 10/23/2023 indicated she had impaired cognitive function or impaired thought processes with interventions to keep the resident's routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion.3. Record review of a facility admission record for Resident #8 dated 10/8/2025 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of COPD (a group of diseases that affect breathing), mild intellectual disabilities (a condition that limits intelligence and disrupts abilities to live independently), hypertension, and chronic kidney disease stage 4 (kidney failure).Record review of a Quarterly MDS for Resident #8 dated 9/1/2025 indicated he had moderate impairment in thinking with a BIMS score of 12. He was independent in eating.Record review of a care plan for Resident #8 revised 5/12/2024 indicated he had ADL self-care performance deficits related to disease processes. Interventions included the was able to feed himself with set-up and supervision to be able to complete meal and have not become too tired to feed himself.4. Record review of an admission record for Resident #12 dated 10/8/2025 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia, bipolar disorder (a mental illness that causes extreme mood swings), type 2 diabetes, and hypertension.Record review of a Quarterly MDS Assessment for Resident #12 dated 8/15/2025 indicated he had moderate impairment in thinking with a BIMS score of 8. He was independent in eating and required supervision or touching assistance with oral hygiene.Record review of a care plan for Resident #12 dated 6/3/2024 indicated he had impaired cognitive function or impaired thought processes. Interventions included to keep the resident's routine consistent and try to provide consistent caregivers as much as possible.5. Record review of an admission record for Resident #5 dated 10/8/2025 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Alzheimer's Disease (a progressive and irreversible decline in memory and cognitive abilities), major depressive disorder (persistent sadness and loss of interest), anemia (decreased production of red blood cells in the body), and BPH (the prostate glands grows larger than normal).Record review of a Quarterly MDS Assessment for Resident #5 dated 9/3/2025 indicated he had severe impairment in thinking with a BIMS score of 3. He was independent with eating and supervision or touching assistance with oral hygiene and toileting.Record review of a care plan for Resident #5 dated 4/21/2025 indicated he had impaired cognitive function or impaired thought processes. Interventions included to present just one thought, idea, questions, or command at a time.Record review of the personnel file for BOM/[NAME] indicated she was hired at the facility on 10/13/2022. She had an initial criminal history check on 10/12/2022. An annual EMR was checked on 1/1/2025 and she was not listed as being unemployable. She had annual training on abuse on 4/1/2025.Record review of a [store name] receipt dated 8/31/2025 at 2:33 p.m., revealed a total purchase was made to buy food items using the food debit card that belonged to Resident #1. The total purchase was $89.00 that was charged. Some food items purchased included: energy drinks, spaghetti noodles, alfredo noodles, etc.Record review of a [store name] receipt dated 8/26/2025 at 2:38 p.m., revealed a total purchase was made to buy food items using the food debit card that belonged to Resident #6. The total purchase was $98.17 that was charged. Some food items purchased included: Starbucks coffee, guacamole, French mustard, and mayonnaise.Record review of a [store name] receipt dated 8/26/2025 at 11:26 a.m., revealed a total purchase was made to buy food items using the food debit card that belonged to Resident #6. The total purchase was $1.68 that was charged.Record review of a [store name] receipt dated 7/26/2025 at 10:55 a.m., revealed a total purchase was made to buy food items using food debit cards that belonged to Resident #1 and Resident #5. The total purchase was $102.33 that was charged to both cards used. Resident #1's card was charged $100.00 and Resident #5's card was charged $2.33. Some food items purchased included: pizza rolls, tater tots, broccoli rice, flour tortillas, etc.Record review of a [store name] receipt dated 7/26/2025 at 10:51 a.m., revealed a total purchase was made to buy food items using the food debit cards that belonged to Resident #8 and Resident #12. The total purchase was $179.04 that was charged to both cards used. Resident #8's card was charged $86.16 and Resident #12's card was charged 92.88. Some food items purchased included: Brussel sprouts, fettuccini, energy drinks, etc.Record review of a [store name] receipt dated 6/28/2025 at 1:47 a.m., revealed a total purchase was made to buy food items using the food debit cards that belonged to Resident #1 and Resident #6. The total purchase was $200.00 that was charged to both cards used. Resident #1 and Resident #6 cards were both charged $100.00 each. Some food items purchased included: New York strip steak, cubed steak, tater tots, instant potatoes, country gravy mixes, baked beans, etc.The total of the receipts reviewed was $670.22.During a confidential interview on 10/6/2025 at an undisclosed time, a complainant reported that the facility had a program where many residents in the facility received a food card that they could use to buy food at [store name]. The complainant reported they had overheard facility staff talk about the person who was over the money in the facility had spent some of the money from the resident's food cards and wanted it investigated.During an interview on 10/6/2025 at 11:44 a.m., the [NAME] said the food cards provided by [insurance company name] allowed the residents who was signed up on the program to buy anything that was edible that included snacks, drinks, etc. She said that each resident that received the benefit received $100 at the beginning of the month. She said some residents kept their cards in their possession and some were in the possession of family members. She said for everyone else their cards were locked in her office for the staff to use to buy items for the residents. She said the Activities Director would shop for most of the residents in the facility along with some of the resident care partners. She said the residents received $100 monthly and the benefits did not roll over, so whatever was not spent each month, they would lose. She said the residents would provide the staff members with a list and the staff would shop for them at [store name] which was the designated store to use the cards. She said the staff was to give her the receipt for purchases when they returned to the facility. She said they had a binder she kept in her office. They started in July 2025 in which the staff was to sign out the cards and sign them back in along with placing the receipts for the purchase in the binder under the resident's name. She said she shopped for some of the residents in the facility as well.During an interview on 10/6/2025 at 11:57 a.m., the LED said some of the residents in the facility received a food card as part of their insurance benefits for $100 monthly and the money did not roll over each month on what they did not spend. She said the program started sometime between December 2024 to January 2025 when she was out for maternity leave. She said she shopped for most of the residents and only a few had cards that was checked out by family to use. She said on the first of every month the cards reloaded with $100. She said every other week she went to the store and shopped for the residents in the facility and would go about 2-3 times a month. She said the residents would give her a list and she would shop for them. She said she had to get their cards if they were not in their possession from the [NAME] and would have to sign the cards out and back in once back in the facility. She said they wrote the resident's names on the receipts so they could keep track of what was spent for each resident and the receipt was placed in the binder. She said there were a few people in the facility that was authorized to shop for the residents, including the [NAME] and RCP B.During an interview on 10/6/2025 at 3:17 p.m., the DRSS said she did not shop for any of the residents in the facility. She said it was done by the LED. She said PTA A called her on the day she was in [store name] when she tried to purchase food for Resident #6 when the card declined. She said she told PTA A to call and speak to the Administrator or the [NAME].During a phone interview on 10/6/2025 at 3:30 p.m., the Transport Driver said she shopped for some of the residents in the facility. She said the last time she shopped for them was Sunday a week ago (9/28/2025). She said a couple of months ago she shopped for Resident #6 but did not remember what date it was. She said Resident #6 was not a snacker and had a twelve pack of sodas that had been in her room for a while. She said when she shopped for the residents, she used their food card that was provided to them by their insurance company. She said the [NAME] would give them the cards and when they returned to the facility, they would print the resident name on the receipt and turn it into the [NAME]. She said she never had a problem with the cards for the residents she shopped for, and all had enough money to buy what they wanted. She said the facility had used the cards for some months. She said she did not remember the facility providing any training or in-service to the staff on the use of the cards.During an interview on 10/6/2025 at 2:50 p.m., PTA A said Resident #6 was a resident at the facility who was like a grandmother to her and the POA had asked her about a month ago (August 2025) to go to the store and purchase some things for her. She said she received the card from the LED and went to [store name] to buy the resident some food items and when she tried to check out, the card declined. She said she called the number on the back of the card and listened to the most recent transactions, and it revealed multiple purchases in June 2025, July 2025 and August 2025 that was close to $100 that was made and the POA had not made any purchases for Resident #6. She said she contacted the POA and discussed what she had discovered and talked to [store name] about video surveillance but was told they could not give her video footage without a police report. She said she reported the information to the facility and was told they would conduct an investigation to see if there were any discrepancies with the food cards.During an interview on 10/6/2025 at 3:09 p.m., the Administrator said the [NAME] was responsible for overseeing the food card program and had the cards locked up until they were needed. She said the LED/Activities Director, DRSS/SW, [NAME]/BOM and some of the resident care partners could use the cards to purchase food items for the residents. She said she was aware of an issue with the use of the cards and had planned to audit last week (9/29/2025-10/3/2025) but did not get a chance to and then planned to the week of 10/6/2025-10/10/2025. She said the LED had used the cards of some of the residents and the cards declined. She said charges were made and thought someone had gone to shop for the residents and did not turn in the receipts. She said she had no idea someone had used the resident food cards for their personal use and just thought someone did not turn in receipts for purchases made.During a phone interview on 10/6/2025 at 3:52 p.m., the POA for Resident #6 said the resident was at the hospital. She said she was made aware by PTA A whom she had asked to buy some food for Resident #6 using her food card that was provided by her insurance company. She said she was informed that when PTA A went to [store name], there was not anything on the card as the card declined. She said she had not talked to the Administrator about the incident and PTA A was going to let her know what to do. She said Resident #6 did not snack a lot and had sodas in her room and had them for a while. She said she was picky with her foods. She said she would wait and see what was discovered about the food cards.During an interview on 10/7/2025 at 12:24 p.m., the Administrator said reviewing the receipts that was requested, she saw some things that were troubling that included large purchases for items such as steaks and multiple resident cards was used for the purchases. She said she filed a police report and was going to start an internal investigation into the matter. She said the officer went to [store name] and reviewed video footage for the dates of the receipts that had large purchase amounts and described the BOM/[NAME] as the person who made the purchases. She said charges would be filed and she would be suspended until her investigation was complete and was going to take possession of the food cards. She was going to in-service staff on proper use of the cards according to their policy. She said they would conduct a complete audit of all residents in the facility who had the food cards on tomorrow 10/8/2025. She said she expected the staff to use the food cards for the people for whom they were designated.Record review of a disciplinary action record signed and dated 10/7/2025 for the [NAME]/BOM by the BOM indicated she was suspended for an allegation of misappropriation of resident funds. The date of occurrence was 6/28/2025.During a follow up interview on 10/7/2025 at 12:28 p.m., the [NAME]/BOM said she had been in the position as the Director of Resident Accounts for about a year. She said she was responsible for keeping up with the food cards for the residents in the facility. She said the program started around January 2025. She said she had made purchases on the weekends on her off time a few months ago. She said the staff were not supposed to be on the clock when they shopped for the residents. When asked about her using the food cards for her personal benefit, she admitted that she had. She said she bought food for herself and had used the cards of Resident #1 and Resident #6. She said she could not remember what other cards she had in her possession at the times she used the cards but there were multiple cards she had with her. She said she knew what she did was wrong and did not have an explanation as to why she did it. She said she knew the residents received $100 each month and whatever they did not use, they would lose. She said she hated that the residents would lose the money when it could have been used. She said she knew it was theft as the cards were not hers and she did not have permission to use their cards for her personal benefit. She said initially when the food card program started at the facility, they were told repeatedly to use the cards and spend the money, if not they would lose the money at the end of the month. When questioned if the facility told her, it was ok for the staff to use the resident cards for their personal use, she said they did not specifically tell her that. She said she made purchases for herself at the end of the month with the resident food cards when she knew they had money left on the cards and they were about to get reloaded. She said she would not like it if someone took advantage of a family member if they were in a facility. She said it would be hurtful to think someone did that to a family member of hers. She said what she did was theft. She said she took an unethical route and accepted full responsibility for her actions. She said she could not remember how many purchases she made but thinks she only used cards for her personal benefit at the end of June and July 2025. She said she had annual training on abuse.During a phone interview on 10/9/2025 at 10:15 a.m., loss prevention manager at [store name] said all the receipts that were in question from June 2025, July 2025, and August 2025 was all purchased by the same person (BOM/[NAME]).During a phone interview on 10/9/2025 at 10:18 a.m., the detective assigned to the case said he was off yesterday 10/8/2025. He said the initial reporting officer indicated in his narrative that the Administrator of the facility had filed a report on 10/7/2025 to report a staff member had been using the debit cards of residents in the facility. He said the investigation was ongoing and the police report would not be available for a while.Record review of a facility policy titled And More Grocery Benefit Card by PPHP dated 1/10/2025 indicated, .The $100 grocery benefit card should be stored in the business office and made available to the responsible party or the resident themselves. The community LED will also be able to support the use of this card as an activity for the residents. This process will support the utilization for the residents' benefit and appropriate use of their funds as it is intended. 1. Storage a. The grocery benefit cards will need to be stored in a secure location in the business office as they are received via mail. Check in & check out process for the cards may only be exercised by the responsible party for the resident, the resident themselves or the community LED. All staff are expected to adhere to the policy provided for the use of this card to maximize and protect residents' supplemental benefits. 2. The EDO will oversee the proper use of these benefits. 3. [NAME] will: c. keep sign out log in binder-require proper ID. D. Keep all receipts received by the LED of the facility.Record review of a facility policy titled Abuse revised 1/27/2020 indicated, .the purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse 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.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safely. The facility did not ensure walls, floors, and equipment were not dirty with a buildup of grease, food and dust on 6/09/2025 and 6/10/2025 in the facility only kitchen. These failures could place residents who received their meals from the kitchen at risk for food-borne illness and food contamination. Findings included: During an observation on 06/09/25 at 8:20 a.m., the floor and baseboards in the dry storage area had a black, dirt buildup. The food preparation and cooking area had dirt and food debris on the floor. The walls located next to the washing station and steam table had visible dirt and grease build up from the baseboards up to approximately 18 inches. The top of the dishwashing machine had visible food debris. The air vents located in the food preparation and dish washing area had visible dust and a black substance on the vent cover. During an observation on 6/10/2025 at 10:30 AM, the floor in the kitchen preparation and wash areas were dirty with dust and food debris. The walls located next to the washing station and steam table had visible dirt and grease build up. During an interview on 06/09/25 at 08:40 AM, [NAME] C said that the kitchen staff was responsible for cleaning the kitchen area. She said the staff tries to clean throughout the shift but sometimes they are not able to clean good until the end of the shift. She stated that the kitchen should be kept clean so that the food was not contaminated. During an interview on 6/10/25 at 10:45 AM, [NAME] D said everybody in the kitchen was responsible for cleaning the kitchen and storage area. She said the tries to clean throughout the shift, but that it gets busy at times and the staff will clean before they leave for the day. She said that a cleaning schedule was followed and employees are assigned tasks to complete daily and weekly. [NAME] D said that food was at risk for contamination if the kitchen was not clean. During an interview on 6/10/25 at 11:00 AM, Dietary Aide E said that all kitchen staff was responsible for cleaning the kitchen and food storage area. She said the cleaning schedule was followed and signed by the staff. She said the dietary manager checked the cleaning schedule. She said that food was at risk for contamination if the kitchen was not clean. During an interview on 6/11/2025 at 8:30 am, the Administrator said the kitchen staff was responsible for cleaning the kitchen area. She said the dietary manager was responsible for oversite of the staff and ensuring that all tasks assigned to the kitchen staff were completed. She said the kitchen was in the process of being updated and remodeled. She said the walls were being replaced or painted as new equipment arrives. She said she was aware of the areas of concern and the facility was currently in the process of repairing and painting the areas of concern. She stated that an outside vender had come to the facility the previous week to power was the kitchen floors. She said that the dirt and grease visible on the wall was from years of use and that the wall coverings were being replaced or deep cleaned and repainted. She said the possible outcome of the kitchen not being clean was food contamination that could cause illness in the residents. Administrator stated moving forward the facility would continue with repairs and updates in the kitchen. The Administrator said that the dietary manager would be responsible for monitoring and in services for staff on kitchen cleaning. During an interview on 06/11/25 at 8:50 am, the Dietary Manager said the kitchen staff was responsible for cleaning the kitchen area. She said that she oversees the staff and the cleaning schedule. She said that staff was expected to keep kitchen area clean throughout the shift. She said deeper cleaning was done at the end of the shift or she will bring in extra staff to deep clean. She stated she also assists with cleaning the kitchen. She said that if the kitchen was not cleaned, there would be a risk of food contamination and resident illness. She stated that the staff would continue to be responsible for cleaning the kitchen throughout the shift and she would continue to work with administration and maintenance to update and clean the kitchen and storage areas. Record review of a monthly kitchen cleaning schedule log indicated full cleaning performed in March 2025, April 2025, and May 2025. Record review of a policy for Kitchen Cleaning Schedule revised November 2023 indicated Food and Nutrition Services Personnel will be responsible to maintaining the cleanliness and sanitation of kitchen. Procedure included It is the responsibility of all employees to follow the cleaning schedule. Written cleaning instructions for each area and piece of equipment will be provided.

Based on observations, interviews, and record reviews 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 1 of 6 staff (CNA H) reviewed for infection control. The facility failed to ensure CNA H washed or sanitized her hands when passing out meal trays to residents on Hall 500 on 6/9/2025. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings included: During an observation of meal service on 6/9/2025 from 1:03 PM to 1:22 PM, CNA H did not wash or sanitize her hands prior to entering/exiting rooms or handling meal trays for the next room for the following rooms on Hall 500: entered room [ROOM NUMBER] and took the meal tray into the room and set up the tray and opened the utensils. She repositioned the resident in bed and exited. She then entered room [ROOM NUMBER] and placed the meal tray on over bed table and exited. She then entered room [ROOM NUMBER] and placed the meal tray on the over bed table and opened sugar packets and poured them into a cup of tea and set up the meal tray for the resident. She exited the room and did not wash or sanitize her hands. During an interview on 6/11/2025 at 9:25 AM, the ADON said she was one of the Infection Preventionists (IP's) in the facility. She said staff should sanitize their hands between residents when passing trays. She said there could be a risk for cross contamination or spreading infections when staff did not wash or sanitize their hands. She said they started an in-service with staff on hand hygiene on 6/9/2025. ADON said staff were trained quarterly on infection control and hand hygiene and they had a competency evaluation for skills back in December 2024. Record review of an in-service dated 6/9/2025 indicated the DON conducted a training on hand hygiene and CNA H was present. During an interview on 6/11/2025 at 9:35 AM, the DON said she and the ADON were the IPs for the facility. She said staff were trained on hand hygiene quarterly. She said there was not a risk for infection control with staff not sanitizing their hands between passing meal trays unless they were providing direct resident care between passing meal trays. During an interview on 6/11/2025 at 10:15 AM, the Administrator said the IPs were the DON and ADON who were responsible for training staff on infection control in the facility. She said she was aware that CNA H did not sanitize her hands between passing meal trays on 6/9/2025. She said the facility immediately in-serviced the staff on hand hygiene. She said if the staff did not sanitize between passing meal trays there could be a risk for cross contamination. Record review of a facility policy titled Hand Hygiene revised 10/24/2022 indicated, . Hand Hygiene is used to prevent the spread of pathogens in healthcare settings. 1. You should always perform hand hygiene: before and after providing any type of care; after contact with medical equipment or other environmental surfaces that may be contaminated .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 vaccine/medication storage refrigerators reviewed for pharmacy procedures. The facility failed on 06/11/2025 to remove expired tuberculin skin testing (TST) solution from the vaccine/medication refrigerator. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings included: During an observation and interview on 06/11/25 at 9:00 AM the vaccine/ medication refrigerator had 1 vial of tuberculin skin testing (TST) solution in the refrigerator with an open date of 4/24 with no initials. The medication storage directions indicated tuberculin skin testing solution was to be discarded after 30 days of opening. The ADON said TST was administered by the nurse on the floor to any resident or staff member needing a TB test. The ADON said using the TST after it had expired to residents could be adverse reactions, medication not as strong as it should be, and false readings. ADON said she assumed the vial had been open on 4/24/2025 but the date read 4/24 with no initials so there was no way to be sure exactly when it was opened. During an interview on 06/11/25 at 9:39 AM DON said that the ADON was responsible for ensuring multi dose vials are labeled and expired medications are discarded. She said not discarding vaccines and testing materials could cause an infective vaccination or false results of tuberculosis testing. During an interview on 6/11/2025 at 10:00 AM, the Administrator said the process for tuberculosis testing was the DON's responsibility. The Administrator said the tuberculin skin testing solution should not be given after the use by date. She expects that staff are trained accordingly and will oversee the DON to ensure all staff are trained. Record Review of policy and procedure titled Storage of Medications dated 09/2018 indicated, .#5. When the manufacturer has specified a usable duration after opening the nurse shall place a date opened sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening, unless manufacturer recommends another date or regulations/guidelines require different dating. Record review of tuberculin skin testing (TST) package insert states to dispose of medication 30 days after opening. Record review of https://www.fda.gov document dated 11/9/2020 reference 22. [NAME] S, et al. Effect of oxidation on the stability of tuberculin purified protein derivative (PPD) In: International Symposium on Tuberculin and BCG Vaccine. Basel: International Association of Biological Standardization, 1983. Dev Biol Stand 1986; 58:545-552. (Dispose of Vial 30 days after opening)

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 6 residents (Resident #17) reviewed for resident rights. The facility failed to ensure the window blinds were closed when personal care was provided on 6/10/2025. These failures could place residents at risk of decreased feelings of self-worth and decreased quality of life. Findings included: Record review of an admission Record for Resident #17 dated 6/11/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of COPD (a group of lung diseases that affect breathing), Type 2 diabetes, major depressive disorder and (low mood, low self-esteem and a loss of interest) heart failure (heart not able to pump effectively). Record review of a Quarterly MDS Assessment for Resident #17 dated 5/29/2025 indicated she had severe impairment in thinking with a BIMS score of 4. She required substantial/maximal assistance with personal hygiene. Resident #17 was always incontinent of urine and bowel. Record review of a care plan for Resident #17 revised on 9/16/2024 indicated she had an ADL deficit from disease process. She required moderate assistance by one staff with personal hygiene. During an observation on 6/10/2025 at 11:25 AM, in the room of Resident #17. Staff members CNA F and CNA G performed personal care. Personal care was provided, they closed the door and pulled the privacy curtain but did not close the window blinds. During care provided a car passed by. During an interview on 6/10/2025 at 11:42 AM, CNA F said she had been employed at the facility for 2 1/2 years and worked day shift from 6 am-6 pm. She said usually when she provided care to a resident in their rooms, she closed the doors and pulled the privacy curtain so if anyone entered the room, they would not be able to see care being provided. She said the normally did not close the window blinds in the room unless the room was at the front of the facility and did not think anyone could see Resident #17's window from the road by the facility. She said the blinds should be closed for all residents as it gave privacy from someone on the outside of the facility. She said it would make her feel exposed if someone had to provide personal care to her and they kept the blinds open. She said she had training on privacy for the residents when care was provided. Record review of a competency evaluation for CNA F dated 2/23/2025 indicated she successfully met the performance criteria for incontinent care that included to provide privacy which included to close the blinds. During an observation on 6/10/2025 at 2:00 PM, outside of the facility from the front parking lot looking into the room of Resident #17, her window blinds were up, and a light could be seen in the hallway. Her door was open, and a person walked down the hallway. During an observation and interview on 6/10/2025 at 8:25 AM, Resident #17 was sitting up in a wheelchair in her room. She said the staff would sometimes close the window blinds when they provided care for her. She said she did not notice it yesterday that the staff did not close the blinds but did not want anyone seeing her. During an interview on 6/10/2025 at 9:25 AM, the ADON said she had been employed at the facility since December 2024. She said staff were to provide privacy when care was provided that included pulling the privacy curtains pulled and making sure window blinds were closed. She said by staff not providing privacy to a resident during care it could be a dignity issue. During an interview on 6/10/2025 at 9:32 AM, CNA G said she had been employed for 5 years. She said she on yesterday 6/10/2025 during care provided to Resident #17, they should have closed the window blinds. She said she did not think about it and was nervous. She said they were to close the doors, pull the privacy curtains and close the blinds when care was provided. She said by them not closing the blinds, a resident could feel like their privacy was being invaded or if people passed by could be able to see in the room. She said it would make her feel uncomfortable if she was not given privacy when care was provided. Record review of a competency evaluation for CNA G dated 12/18/2024 indicated she successfully met the performance criteria for incontinent care that included to provide privacy which included to close the blinds. During an interview on 6/10/2025 at 9:35 AM, the DON said she was made aware of the staff who failed to close the window blinds when care was provided to Resident #17 on yesterday 6/10/2025. She said it was a dignity issue and window blinds should be closed and privacy curtain pulled when care was provided. She said she planned to in-service and train staff on providing privacy. She said the facility did not have a policy on dignity but in the competency skills evaluation for the nursing staff it instructed them to provide privacy and close the blinds. During an interview on 6/10/2025 at 10:15 AM, the Administrator said she was made aware of the staff that did not close the window blinds when care was provided. She said the staff would be retrained by an in-service. She said residents could feel embarrassed if the staff did not close the blinds when care was provided. She said the facility did not have a policy for dignity.

Based on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety that also consider non-smoking residents for 1 of 2 smoking areas (secured unit smoking area) reviewed for smoking safety. The facility failed to ensure paper and plastic trash were not discarded into the fire safety can on 6/09/2025. This failure could place residents at risk of injury, burns, and an unsafe smoking environment. Findings included: During an observation on 06/09/25 at 9:03 AM the designated smoking area off the secured unit was observed with one fire can that contained cigarette butts, 1 plastic bottle and an empty cigarette package. There was no ashtray in the area. During an interview on 06/09/25 at 9:04 AM CNA A said the housekeeping staff were responsible for cleaning the fire can daily. She said smokers were supervised during smoking and there were no ashtrays because the residents dug in them. CNA A said they put the resident's cigarette butts in the fire can because it had a lid and there should not be any trash in the fire can because it was a fire hazard. During an interview on 06/10/25 at 3:20 PM Housekeeper B said that the housekeepers were responsible for cleaning the designated smoking areas daily. She said the staff that supervise the smokers should also make sure that the fire cans did not have any trash and was only for cigarette butts. Housekeeper B said trash in the fire can could result in a fire. During an interview on 06/11/25 at 8:23 AM the Administrator said that housekeeping was responsible for maintaining the designated smoking areas and cleaned them daily. She said the staff supervising the smokers should also be checking for any trash in the fire cans and expected staff to regularly inspect the area before and after smoke breaks for any fire hazards. Administrator said trash in the fire can could cause a fire. Record review of a facility policy titled Smoking dated 10/12/2022 revealed, .policy of this community to provide a safe environment, 2. smoking by residents is allowed with the following safety measures readily available: ashtrays made of noncombustible material, metal containers with self-closing covers into which ashtrays can be emptied .

Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 1 of 2 shower rooms (Hall 100) observed for resident environment. The facility failed to ensure the shower rooms in the facility were clean. There was a black substance on the bathroom tiles and walls on 6/10/2025. This failure could place residents at risk for an unsafe environment and unsanitary environment. The findings included: During an interview on 6/9/2025 at 3:11 PM, residents in a confidential resident council meeting said the shower room on Hall 100 needed to be clean and always had clothes and feces on the floor. During an observation on 6/10/2025 at 10:18 AM, the shower room on Hall 100 revealed two shower stalls. One (1) stall had a black substance on the walls and floor where they meet, along with cracked tiles and there were not any baseboards present. In the other stall (2) it had detached baseboards. A used, dirty towel was on the floor. During an observation and interview on 6/10/2025 at 2:59 PM Housekeeper B was on Hall 100 and said she had been employed at the facility for 2-3 months and rotated the halls daily. She said housekeepers were responsible for cleaning the shower rooms during their shift daily. She said the housekeeping staff were supposed to clean the sinks, toilets, shower chairs and wipe down the shower area along with mopping and sweeping. She said if they noticed anything that required attention or repair, they were instructed to notify the Housekeeping Supervisor. She observed the shower room on Hall 100 and said she had cleaned it earlier. She said one of the stalls had a black substance on the walls and floors and it had been that way since she started. She said the other stall had baseboards that were not completely attached. She said the shower room had been in that condition since she started at the facility. She said she was not sure what the black substance was on the walls and floors. During an observation and interview on 6/10/2025 at 3:01 PM, the Housekeeping Supervisor said the housekeeping staff were responsible for cleaning the shower rooms daily after the nurse aides picked up the linens. She said they deep cleaned the shower rooms twice a week and used a disinfectant spray to clean. She observed the shower room on Hall 100 and said the black substance on the walls and floors looked like glue from the baseboards that were not present. She said the baseboards came off a while ago and were never replaced. She said the shower area had tiles that were cracked that needed to be replaced. The other stall in the shower room said it had baseboards that were not completely attached. She said the Maintenance Supervisor would be responsible for repairs in the shower room. She said she would not want to take a shower in there. During an observation and interview on 6/10/2025 at 3:12 PM, the Maintenance Supervisor said he had been employed at the facility since the first of May 2025. He said he was aware of the shower room for Hall 100, and it was on a list of repairs to be done for the facility. He observed the shower room on Hall 100 and said the walls had a black substance mildew that was present on the walls and floors and one of the stalls had missing baseboards and broken tiles. He said the shower room needed a deep cleaning and resealing of the walls and baseboards. He said a plan was in place to complete the repairs but had not been a priority. He said he would have a hard time wanting to shower in that room. During an observation and interview on 6/10/2025 at 3:18 PM, the Administrator observed the shower room on Hall 100 and said she was aware of some issues in the shower room. She said it had been discussed with the facility's corporate staff and had talked about taking up the baseboards as they were not appropriate in the shower room and were planning to install proper flooring. She said the shower room was dirty and needed to be cleaned. She said the black substance on the walls and floors looked like glue and the floors had some cracked tiles. She said she would not want to use the shower room. She said she planned to get the Maintenance Supervisor to start working on the shower room. Record review of a facility policy titled Quality of Life-Homelike Environment revised May 2017 indicated, .2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary, and orderly environment .

Based on observation, interview and record review the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 2 of 2 days reviewed (6/10/2025 and 6/11/2025) for nurse staffing posting. The facility failed to post accurate daily staffing information on 6/10/2025 and 6/11/2025. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts. Findings included: During an observation on 6/10/2025 at 7:45 AM, the daily staffing census information was posted by the front entrance on a wall dated 6/9/2025. During an observation on 6/11/2025 at 8:14 AM, the daily staffing census information was posted by the front entrance on a wall dated 6/9/2025. During an interview on 6/11/2025 at 8:16 AM, the ADON said she and the DON were responsible for posting the daily staffing census information. She said she was not sure why the posting was not put out up yesterday 6/10/2025. She said the posting showed the staff coverage for the facility based on the census for the residents and if it were not posted then family or visitors would not have the information. ADON said she was about to post the daily census information for today 6/11/2025. During an interview on 6/11/2025 at 9:35 AM, the DON said she was responsible for putting up the daily staff posting. She said she forgot to put it up yesterday 6/10/2025. She said the posting was put up so people would know who was staffed in the facility. During an interview on 6/11/2025 at 10:26 AM, the Administrator said the DON was responsible for putting up the daily staff posting. She said the posting was put up so that residents and families could see what staff were in the facility for the day. She said if the posting were not put up then visitors and residents would not be able to see how the facility was staffed. Record review of a facility policy titled Posting Direct Care Daily Staffing Numbers revised July 2016 indicated, .Our facility will post, on a daily basis for each shift, the number of personnel responsible for providing direct care to residents. 1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses and the number of unlicensed nursing personnel directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clean and readable format .

Based on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 4 of 7 residents (Resident #3, Resident #4, Resident #5 and Resident #6) reviewed for abuse and neglect. 1. The facility failed to prevent a Resident-to-Resident altercation when Resident #3 and Resident #4 began fighting and both residents fell to the ground in the smoking area on 11/30/2024. 2. The facility failed to protect Resident #6 from abuse from an Unidentified Resident on 1/5/2025 when an Unidentified Resident grabbed Resident #6 by the arm and threatened him. 3. The facility failed to prevent a Resident-to-Resident altercation when Resident #5 hit Resident #3 with a walker and then began fighting and both residents fell to the ground in the dining room on 2/15/2025. 4. The facility failed to protect Resident #6 from abuse from Resident #3 on 3/25/2025 when Resident #3 kicked Resident #6 in the dining room at breakfast. An Immediate Jeopardy (IJ) situation was identified on 4/16/2025. While the IJ was removed on 4/17/2025, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings include: 1. Record review of the electronic face sheet for Resident #3 indicated the resident was admitted to the facility on [DATE] with the most recent readmission on 4/2/2025. Resident #3 had diagnoses which included: bipolar disorder (significant shifts in mood, energy, and activity levels, causing periods of intense highs and lows), impulse disorder (difficulty controlling impulses, urges, or behaviors, leading to harmful or inappropriate actions), Parkinson's (neurological disorder that primarily affects movement) and Wilson's disease (causes copper to build up in the liver, brain, and other organs). Record review of Resident #3's admission MDS assessment, dated 2/8/2025, indicated a BIMS of 15, which indicated no cognitive impairment. Record review of Resident #3's care plan, dated 11/15/2024, indicated: I am exhibiting behavior of making flirtatious comments towards staff and some female residents. Interventions included: 1. [Counseling] services evaluate and treat. 2. Monitor/document/report PRN any signs/symptoms of resident posing danger to self and others. 3. Staff will monitor for safe environment and to ensure no unusual episodes occur. The care plan dated 3/4/2025, indicated I am exhibiting behavior of-verbal aggression to other residents, I like to 'stir the pot', boss people around and tell people what they can and can't do. I am often loud and obnoxious and often instigate arguments with staff and residents. Interventions included: 1. Monitor/document/report PRN and signs/symptoms of resident posing danger to self and others. 2. Psychological services evaluate and treat. 3. Staff will monitor for safe environment and to ensure no unusual episodes occur. 4. When the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away and approach later. Record review of the facility's incident report for Resident #3, dated 2/15/2025 at 2:38 PM, completed by LVN A, indicated: Heard loud noises coming from dining room, when arrived to dining room, saw resident sitting on floor along with the other resident. Resident stated the CNA was in the way and [Resident #5] asked him to move and resident yelled back at him. Resident stated they both were going back and forth. [Resident #5] got angry and hit him on top of his head with walker. Staff member broke incident up. 2. Record review of the electronic face sheet for Resident #4 indicated the resident was admitted to the facility on [DATE] with the most recent admission on 3/27/2025. Resident #4 had diagnosis which included: vascular dementia (difficulty thinking, memory and behavior), Hemiplegia (paralysis on the left side of the body) and muscle weakness. Record review of Resident #4's admission MDS assessment, dated 4/4/2025, indicated a BIMS of 13, which indicated no cognitive impairment. It also indicated Resident #4 was independent with walking 150 feet. Record review of Resident #4's care plan, dated 11/15/2024, indicated: I have a ADL self-care performance deficits related to disease processes. I am mostly independent with ADLs with some assistance with set-up and supervision with locating thing. I have left side hemiplegia and walk with a cane. Interventions included: 1. Transfer: The resident requires supervision and set-up assistance by 1 staff to move between surfaces as necessary. Record review of the facility's incident report for Resident #4, dated 11/30/2024 at 6:45 PM, indicated: Resident stated he was outside smoking when he and another male resident started arguing, he stated he walked up to the other resident and the other resident pulled himself up out of his wheelchair using him they began hitting one another and fell to the ground. The notes section indicated: Resident involved in physical altercation with [Resident #3]. Resident had words with other resident and both decided to show who was boss. Few slaps back and forth, easily redirected by staff present. No injury noted or complaint of pain. Both residents redirected to their room and further smoke breaks this evening. Record review of the facility's progress note for Resident #4, dated 11/30/2024 at 7:31 PM, completed by LVN C, indicated: This nurse was at the medication cart when a dietary worker came in the hallway and stated 'hey they need some help out here.' Nurse went to the dining room and the door leading out to the smoke area was open. Resident was observed laying in the smoke area with the other male resident beside him and they were both arguing and still trying to engage physically. Nurse stepped between them and assisted this resident up. Resident was assisted back in the facility and sat in a chair. After he got his shoes back on he was assisted to his room. Resident described in his words what happened. DON was notified. Resident was instructed to stay away from the other male resident and there would be no other smoke breaks for him. Resident did not have any visible physical injuries after assessment. Denies any physical or emotional distress 3. Record review of the electronic face sheet for Resident #5 indicated the resident was admitted to the facility on [DATE]. Resident #5 had diagnoses which included: toxic encephalopathy (brain disorder caused by exposure to toxic substances), chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe) and type 2 diabetes (high blood sugar). Record review of Resident #5's quarterly MDS assessment, dated 2/5/2025, indicated a BIMS of 14, which indicated no cognitive impairment. It also indicated Resident #2 was independent with walking 150 feet. Record review of Resident #5's care plan, dated 2/21/2025, indicated: The resident was/has potential to be physically aggressive hit another resident with walker, related to anger, poor impulse control 2/15/25-became impatient with another resident and hit that resident with walker. Interventions included: 1. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document . 3. Monitor/document/report PRN any s/sx of resident posing danger to self and others. 4. Offer psych or psychology services as needed. 5. Social Worker to talk and evaluate resident after any incidents. 6. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Record review of the facility's progress notes for Resident #5, dated 2/15/2025 at 3:16 PM, completed by the LVN A indicated: Resident had a witnessed physical altercation with another resident. Resident was found sitting on the floor in front of his walker. Resident denies pain or discomfort at this time. Resident vital signs are stable. No injuries noted at this time. 4. Record review of the electronic face sheet for Resident #6 indicated the resident was admitted to the facility on [DATE]. Resident #6 had diagnoses which included: intracerebral hemorrhage (stroke), Hemiplegia (paralysis on the right side of the body), and muscle weakness. Record review of Resident #6's annual MDS assessment, dated 2/25/2025, indicated a BIMS of 03, which indicated severe cognitive impairment. It also indicated Resident #6 required substantial to maximal assistance with transfers. Record review of Resident #6's care plan, dated 1/5/2025, indicated: I received physical and verbal aggression from another resident when he was grabbed by the hand and another resident told him he would knock the hell out of him. I am still protective of other residents and may act aggressively towards others. Interventions included: 1. Resident will be assessed for emotional distress and physical injuries after incident and as needed. 2. Resident will be redirected when appropriate. 3. Resident will not go on the same smoke breaks as physically aggressive resident . 5. Staff will monitor for safe environment and to ensure no unusual episodes occur. Record review of the facility's incident report for Resident #6, dated 1/5/2025 at 8:30 am, indicated: Resident was in dining room near the smoking door with another resident when his w/c bumped into the other resident's chair. The other resident grabbed his and told him if he did it again he would knock the shit out of him. Residents were separated and no further physical contact was made. Resident was assessed for injuries with none observed. Resident showed no signs of emotional trauma. Residents will not go on the same smoke breaks together. 5. Record review of the electronic face sheet for Resident #7 indicated the resident admitted to the facility on [DATE] with the most recent admission on 10/31/2022. Resident #7 had diagnoses diagnosis which included: major depressive disorder (persistently low mood), chronic respiratory failure with hypoxia (lungs cannot adequately provide oxygen to the blood), and muscle weakness. Record review of Resident #7's quarterly MDS assessment, dated 2/18/2025, indicated a BIMS of 15, which indicated no cognitive impairment. It also indicated Resident #4 required supervision or touching assistance with walking 150 feet. Record review of Resident #7's care plan, dated 4/15/2022, indicated: I may have a potential for Coping Impaired related to situational and social factors including loss of autonomy or independence; disrupted family life, grief, loneliness, helplessness, or hopelessness. I am seeing counselor at facility and have visits with [Psychiatrist] as needed. Interventions included: Monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing medication or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. During an interview on 4/15/2025 at 10:48 AM, Resident #5 said Resident #3 was in the way while he was trying to get out the door to the smoking area. He said he asked him to let him get by and he said Resident #3 talked noise and cussed him out. He said Resident #3 was agitated and spoke in Spanish. He said Resident #3 turned around and was raising up out of his chair like he was going to fight. He said he then hit him with his walker. He said they both fell on the floor in the dining room. He said Resident #3 called the police and they came and talked to him and told him the next time they would take him to jail. He said if Resident #3 acted that way again he would hit him again. He said that had been the only physical incident he had with Resident #3. He said there was another guy on the 300 hall, Resident #4 had a physical altercation with Resident #3. He said Resident #3 had problems with a lot of residents because he was always in other people's business and cussing other residents. During an interview on 4/15/2025 at 11:11 AM, Resident #7 said she called bingo when the activity director couldn't and said Resident #3 yelled out at her when she called bingo like a bully would. She said they sent Resident #3 to a behavioral hospital because he was physical with Resident #6. She said they initially put Resident #3 on another hall, but he was now back on her hall. She said Resident #3 would throw things. She said Resident #6 was really the only resident she had ever seen Resident #3 kick or get physical with. She said he kissed the older ladies', hands a lot and did not feel it was appropriate. She said one lady (unknown) finally yelled at him to stop and leave her alone. She said Resident #3 did a lot of cussing and calling people names. She said Resident #3 had asked her for sex, and she turned him down and he didn't like it. She said he asked a lot of the ladies and employees for sex. She said she was not afraid of him physically, but she was afraid of what he brought out in her and was afraid she would hit him. She said one time they got in an argument, and he tried to charge at her, and staff pulled him back. She said she felt so much better when he resided on a different hallway. She said he had just moved back to this hall yesterday 4/14/2025 because he got into an altercation with his roommate on the 300 hall and his roommate called the police. She said all altercations or arguments were always centered around Resident #3. During an interview on 4/15/2025 at 11:25 AM revealed Resident #6 could not answer questions due to a diagnosis of aphasia (language disorder that results from damage to the brain's language centers). During an interview on 4/15/2025 at 11:31 AM, CNA D said Resident #3 moved back to the 500 hall yesterday 4/14/2025. She said she did not know what prompted the move back to the 500 hall. She said Resident #3 was smart mouthed and disrespectful to staff and residents. She said a staff member would be talking to another resident and Resident #3 would chime in with his negative input. She said she had seen the arguing with Resident #3 but had never seen him get physical with anyone. During an interview on 4/15/2025 at 12:52 PM, the ADON said he was an instigator and liked to create tiffs until other residents went off on him. She had been employed at the facility since December 2024, Resident #3 was sent to a behavioral hospital and had 2 room changes, and medication changes. She said the SW was sending out referrals to discharge Resident #3, but no one would accept him. During an interview on 4/15/2025 at 1:13 pm, the DON said Resident #3 liked to stir the pot and instigate arguments with residents and staff. She said Resident #3 had been in a group home and multiple nursing homes prior to being at the facility. She said Resident #3 had issues when he was living at home with his mother and thought that adult protective services had been involved because Resident #3 had acted out and called the police many times while he was there. She said Resident #3 was sent to after he kicked Resident #6 at breakfast. During an interview on 4/16/2025 at 10:01 am, the SW said on 3/25/25 Resident #3 kicked Resident #6 during breakfast because he was making some noise and Resident #3 did not like it. She said he came to her office that morning and said he had kicked Resident #6 but did not know why he did it. She said on 2/15/25 the residents were going out to smoke and Resident #3 was in the doorway and Resident #5 was telling him to go go go and he said he couldn't go so he was cussing Resident #5, and Resident #5 picked up his walker and hit Resident #3, and both residents began fighting and fell on the floor. She said Resident #3's head was sore from being hit and he had an abrasion but otherwise there were no other injuries. She said she saw the video footage and could not tell if Resident #3 was hit on the head or shoulder area. She said on 11/30/2024 Resident #3 and Resident #4 were outside in the smoking area and were going back and forth arguing and both residents ended up on the ground. She said she couldn't remember if either one actually hit the other one. She said she couldn't remember any other physical altercations she was aware of. She said Resident #3 was referred to counseling services on 11/5/24 but refused. She said on 2/19/25 the order and consent were received for counseling services, and he was evaluated by the counselor on 2/26/25. She said he had a verbal altercation a few days earlier and if another incident happened then they needed to seek further help for him. She said the Resident #3 received counseling services on Wednesday and the Psych MD and saw him monthly. She said she sent out 6 referrals to seek alternate placement for Resident #3 between 4/1/2025 and 4/15/2025 and all had been denied. During an interview on 4/16/2025 at 11:50 am, the Administrator said Resident #3 had a history of behaviors. She said she knew Resident #3 had behaviors before the resident was admitted to the facility, but she accepted him anyway because she felt like they could help Resident #3. She said Resident #3 liked to instigate and stir the pot with other residents and staff. She said Resident #3 often inserted himself into conversations with staff and residents who were not about him. She said Resident #3 knew what he was doing and would often apologize after an altercation with staff or other residents. During an interview on 4/16/2025 at 1:21 PM, Resident #3 said when he was 28 he was in the hospital for 2 months and that's when he was diagnosed with the Wilson's disease. He said he is a sweet guy but when you him make him mad, he turns into the devil. He said he did not receive counseling services at the facility. He said he had only talked to a counselor 1 time since he had been at the facility. He said when he had the incidents with other residents he would go and apologize after the incident was over. He said he did not have control over his actions when he got mad and he got anxious. He said he told Resident #4 to tie his shoe and Resident #4 told him to shut up and for him to tie it and said he got up and started walking over to him and they just began fighting and fell to the ground in the smoking area. He said Resident #5 told him to go out the door and he said Resident #5 took his walker and put it over his head and jerked it back as if to choke him. He said he kicked Resident #6 because he was jealous the staff were feeding Resident #6 and not him. He said he went to the behavior hospital after he kicked Resident #6. He said he got kicked out of another nursing facility for trying to bite the medication aide's finger. During an interview on 4/17/2025 at 1:25 PM, Resident #4 said he did not like Resident #3 and said on the day in question he was in the smoking area. He said Resident #3 told him his shoe was untied and he told Resident #3 it was none of his business. He said Resident #3 would not leave him alone and he got mad and him and Resident #3 mutually began fighting and fell on the ground. He said after the incident he did not like Resident #3, but he just tried to stay away from him and stay out of trouble. During an interview on 4/22/2025 at 9:28 AM, LVN A said on 2/15/2025 someone came and got her and let her know Resident #3 and Resident #5 were fighting in the kitchen. She said Resident #5 told her Resident #3 was talking bad to him. She said Resident #5 said he hit him. She said when she asked Resident #3 what happened he said Resident #5 was talking to someone else and Resident #3 got in their business and started the argument with Resident #5. She said both residents fell on the floor in the dining room. She said Resident #3 was always in someone else's business. She said she thought Resident #3 was just angry because he was in the nursing home. She said Resident #3 would wake up and just be mad at the world. During an interview on 4/22/2025 at 10:14 AM, CNA E said on 2/15/2025 she was taking the smokers out and stook in the doorway. She said she heard Resident #5 tell Resident #3 to go and he said don't you see CNA E in the way. She said she didn't hear him say anything else and then Resident #5 put his walker over Resident #3 like he was trying to choke him with it. She said then Resident #3 started shaking and fell on the floor. She said Resident #3 called the police. Said she thought both residents had been arguing prior to the incident. She said Resident #3 could not get along with anyone. Record review of the facility's policy titled Abuse, dated 2/1/2017, reflected: The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement, and or Misappropriation of property . Residents will not be subjected to abuse by anyone, including, but not limited to community staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, care taker, friends, or other individuals . This was determined to be an Immediate Jeopardy (IJ) on 04/16/2025 at 5:42 PM. The facility Administrator was notified. The Administrator was provided with the IJ template on 4/16/2025 at 5:42 PM. The following Plan of Removal submitted by the facility was accepted on 4/17/2025 at 2:07 PM: 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 April 16, 2025, at 5:45 PM. F600 Abuse 11-30-24: Resident #3 was assessed on 11-30-24 after incident and had scratches to left arm that were treated in house. Resident #4 was assessed on 11-30-24 after incident and had no injuries or physical or emotional distress. DCO and LVNs redirected residents to their rooms and with no further smoke breaks for them that evening. Psych Services conducted a patient care call with Resident #3 on 12-2-24 with a new order for an increase to his Depakote ER to 1500 mg qhs. Psych Services conducted a patient care call with Resident #4 on 12-2-24 with no new orders. 2-15-25: Resident #3 was assessed on 2-15-25 after incident and had a small abrasion to right midback. Resident #5 was assessed on 2-15-25 after the incident and had no injuries. Police were called and they came and spoke to both residents and left. DRSS spoke with both residents individually on 2-17-25, and they reported no emotional effects from the incident and both residents were offered counseling services, which were refused. Psych services conducted a patient follow up visit on 2-18-25 on Resident #3 with no new orders or interventions. Resident #3 was reeducated on counseling services on 2-19-25 and agreed to the service and signed consent for treatment. Resident #5 refused counseling services again on 2-18-25. 3-25-25: Resident #3 was discharged to Behavioral Hospital on 3-25-25 for behaviors. Resident #6 was assessed on 3-25-25 after the incident with no injuries. Psych Services visited Resident #6 on 3-29-25 with no new orders. Immediate Action All staff in-serviced on April 16, 2025, by Executive Director of Operations (EDO)/Director of Clinical Operations (DCO) and/or designee on the following topics: Prevention, Identification and Reporting/Investigation of Abuse; How to Immediately Protect Residents when abuse is suspected; Possible Interventions to Assist with De-escalation after an Incident. All staff not present at time of in-service will not be permitted back to work until in-service is complete. 4-16-25: Resident #3 was placed on one-to-one monitoring at 7:20pm. Discharge Planning initiated to family. Family agreed by phone to discharge resident to their care on 4-16-25 at 9pm. Resident remained on one-to-one monitoring until discharge on [DATE] at 7:52am. 4-16-25: Safe Surveys were conducted by DRSS and/or designee with all residents cognitively able to participate. Results of and action after Safe Surveys are as follows: 3 residents expressed that Resident #3 was rude- Resident #3 was on one-on-one monitoring, 1 resident expressed that a nurse was unsure of what to do for his wound care-resident no longer in facility, 1 resident expressed a CNA was rough during her bed bath-the resident was reinterviewed by DCO to get details, the resident did not think the CNA had been abusive or intentionally rough, it was determined that due to her current clinical condition she requires 2 person assistance for bed mobility and personal care, the care plan and tasks were updated on 4-17-25, One-on-one in-service to be completed on 4-17-25 with CNA. 4-17-25: All residents identified as at risk for physically aggressive behaviors were reviewed by the CRC/ADCO to ensure they had an accurate care plan, appropriate interventions and appropriate Psych Services or Counseling Services The DCO/ADCO/EDO will monitor EMR documentation including the 24-hour report, incident reports and alerts, and Grievances to identify potential abuse or situations requiring further investigation during morning meeting. Abuse allegations will be reported and investigated according to company policy and THHS regulations. Potential abuse or situations requiring further investigation will be documented on a Grievance form with any investigation documentation attached. All staff in-serviced on April 17, 2025, on the Grievance process and utilizing the Grievance form to document the potential abuse or situation and the investigation. The Medical Director was initially made aware on April 16, 2025, of the immediate jeopardy, and has been involved in the development of the plan to remove during an abbreviated QA. These conversations are considered a part of the QA process. Next schedule QA meeting set for April 21, 2025 at 12pm. All in-servicing began on 4/16/2025. This plan was initially implemented on 4/16/2025 and will be monitored, through personal observation, through completion by Regional [NAME] President of Operation and Regional Director of Clinical Services. Monitoring of the Plan of Removal included the following: During interviews on 4/17/2025 between 3:56 PM and 4:32 PM the following staff across multiple shifts were able to appropriately describe abuse, ways to prevent abuse, de-escalation techniques of abuse, 1 to 1 monitoring and the grievance process: CNA F, LVN G, LVN H, CNA J, Floor Tech, CNA K, LVN L, CNA M, Activity Director, CNA N, Cook, Dietary Aide, and CNA E. Record review of skin assessment dated [DATE] for Resident #3. Record review of skin assessment dated [DATE] for Resident #3. Record review of behavioral hospital paperwork for Resident #3 dated 3/25/2025 through 4/2025. Record review of in-service, dated 4/16/2025, on the following topics: Prevention, Identification and Reporting/Investigation of Abuse; How to Immediately Protect Residents when abuse is suspected; Possible Interventions to Assist with De-escalation after an Incident with 39 staff signatures. Record review of every 15-minute monitoring for Resident #3 revealed 1 to 1 monitoring started on 4/16/2025 at 7:30PM and ended on 4/17/2025 at 7:52AM when Resident #3 discharged from the facility. Record review of 66 safe surveys conducted on 4/16/2025 with no noted concerns. Record review of inservice dated 4/17/2025 for completing grievance/complaint investigation report for with 11 staff signatures. The Administrator was informed the Immediate Jeopardy was removed on 4/17/2025 at 4:35 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review the facility failed to have evidence that all alleged violations were thoroughly investigated and prevented further abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 3 of 7 residents (Residents #3, Resident #4 and Resident #6) reviewed for abuse/neglect. The facility failed to prevent further potential abuse and mistreatment of Resident #4 and Resident #6 by allowing the alleged perpetrator Resident #3 to remain in the facility and to have direct contact with the residents. An Immediate Jeopardy (IJ) situation was identified on 4/16/2025. While the IJ was removed on 4/17/2025, the facility remained out of compliance at a scope of a pattern with the potential for more than minimal harm due to the facility need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for abuse, physical harm, psychosocial harm, trauma, unrecognized abuse and emotional distress. The findings include: 1. Record review of the electronic face sheet for Resident #3 indicated Resident #3 admitted to the facility on [DATE] with the most recent readmission on 4/2/2025 with diagnosis that included: bipolar disorder (significant shifts in mood, energy, and activity levels, causing periods of intense highs and lows), impulse disorder (difficulty controlling impulses, urges, or behaviors, leading to harmful or inappropriate actions), parkinsons (neurological disorder that primarily affects movement), wilsons disease (causes copper to build up in the liver, brain, and other organs). Record review of Resident #3's admission MDS assessment dated [DATE] indicated a BIMS of 15, which indicates no cognitive impairment. Record review of Resident #3's care plan dated 11/15/2024 indicated: I am exhibiting behavior of making flirtatious comments towards staff and some female residents. Interventions included: 1.[Counseling] services evaluate and treat. 2. Monitor/document/report PRN any signs/symptoms of resident posing danger to self and others. 3. Staff will monitor for safe environment and to ensure no unusual episodes occur. The care plan dated 3/4/2025 indicated I am exhibiting behavior of-verbal aggression to other residents, I like to stir the pot, boss people around and tell people what they can and can't do. I am often loud and obnoxious and often instigate arguments with staff and residents. Interventions included: 1. Monitor/document/report PRN and signs/symptoms of resident posing danger to self and others. 2. Psychological services evaluate and treat. 3. Staff will monitor for safe environment and to ensure no unusual episodes occur. 4. When the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away and approach later. Record review of facility incident report for Resident #3 dated 2/15/2025 at 2:38pm completed by the LVN A indicated: Heard loud noises coming from dining room, when arrived to dining room, saw resident sitting on floor along with the other resident. Resident stated the CNA was in the way and [Resident #5] asked him to move and resident yelled back at him. Resident stated they both were going back and forth. [Resident #5] got angry and hit him on top of his head with walker. Staff member broke incident up. Record review of nursing progress notes, dated 1/1/2025 at 4:30 PM, written by the LVN P, indicated: [Resident #3] is verbally aggressive towards another resident. Intervened at this time and DON aware. Record review of nursing progress notes, dated 1/6/2025 at 12:38 PM, written by the SW, indicated: Spoke to [Resident #3] about an incident that occurred during a smoke break on 01/05/25. [Resident #3] stated that a male resident was hollering, cussing and calling his friend/another resident racial slurs. [Resident #3] said that he started to holler back at the male resident since his friend could not defend himself. [Resident #3] stated he was fine with the other resident now and that he just puts his headphones in his ears during smoke breaks to avoid the other resident. [Resident #3] was encouraged to keep doing that and to avoid any other future conflicts with the male resident. Record review of nursing progress notes, dated 1/24/2025 at 9:59 AM ,written by the SW, indicated: Spoke to [Resident #3] about the way he talks to other residents in the facility. [Resident #3] stated he cares for some of the residents and wants to teach them and keep them from getting into things they are not supposed to. Educated [Resident #3] that when he cusses, hollers and tells other residents what to do - it is not helping them. Informed [Resident #3] to let the staff redirect other residents. [Resident #3] understood and stated he would stop 'getting onto' and hollering at residents. Record review of nursing progress notes, dated 2/19/2025 at 3:25 PM, written by the SW, indicated: Spoke with [Resident #3] with EDO regarding comments that resident was making towards staff, and reports of him touching female staff inappropriately. Education was provided to resident on why the statements he was making, and his actions were not appropriate. Also educated [Resident #3] that the facility cannot tolerate him touching the female staff on the bottoms or anywhere else [Resident #3] stated he understood and would not do those things anymore. [Resident #3] was educated on [counseling] clinical services to help with these behaviors and [Resident #3] agreed to these services. Record review of nursing progress notes, dated 2/20/2025 at 3:46 PM, written by the SW, indicated: Spoke with [Resident #3] with EDO regarding behaviors that were observed by staff today. Educated [Resident #3] again on the expectations that the facility has for him on his treatment towards staff and other residents. [Resident #3] stated that he is 'trying to remember when we talked last, and to do better.' [Resident #3] stated he understood that he is not supposed to touching staff inappropriately, other residents or cursing towards staff and residents. Educated [Resident #3] again on reporting to nursing staff if he has a concern with other residents - that he should not try and 'help' the resident himself. [Resident #3] stated he understood and that he wants to stay at the facility. [Resident #3] was informed that alternate placement would be considered if resident's behaviors continued. [Resident #3] is now receiving services from Psychiatry and [counseling] Clinical Services to help with behaviors. Record review of nursing progress notes, dated 3/16/2025 at 3:03 PM, written by the RN O, indicated: [Resident #3] was heard yelling at another resident to pull his pants up. Both residents were yelling at each other. Resident was redirected to the dining area. Record review of nursing progress notes, dated 3/24/2025, written by the SW, indicated: Care Plan meeting with resident, Ombudsman, DCO, ADCO and DRSS. Discussed residents behavior towards staff and how the facility will not tolerate them. Ombudsman educated resident on his rights and other residents rights and education on the facility discharging him if behaviors continue. Resident stated he understood and that he wanted to stay at the facility. Resident also stated that he understands that he should not holler and 'pick on' other residents. DCO and ADCO educated resident on all interventions the facility have made to improve behaviors and resident stated he understood. Resident stated he would limit behaviors. Record review of nursing progress notes, dated 3/25/2025 at 8:09 AM, written by LVN A indicated: It was reported to this nurse that [Resident #3] kicked another resident for no reason this morning at breakfast time. Staff CNA was feeding another resident and [Resident #3] decided to kick him multiple times. Resident is aware of possible consequences of his actions. Notified [DON]. Record review of nursing progress notes, dated 3/25/2025 at 8:16 AM, written by the SW, indicated: [Resident #3 came into DRSS office stating, 'I have to tell you something before anyone else does.' [Resident #3] stated that he 'kicked' another male resident during breakfast and that he did it for no real reason. [Resident #3] stated he knew it was wrong and that he would apologize to male resident. [Resident #3] went to doorway of my office and said 'I'm sorry' to male resident then asked if this SW heard him apologize. Reminded [Resident #3] that we just had a meeting yesterday with the ombudsman about his behaviors towards other residents. [Resident #3] stated he remembered the meeting and that is why he wanted to tell me and apologize. Record review of nursing progress notes, dated 4/14/2025 at 7:28 AM, written by the ADON, indicated: This nurse was in office when a verbal altercation between this [Resident #3] and roommate. [Resident #3] states that his roommate was on the phone and 'he was lying to whoever he was talking, all he does is lie when what he needs to do is get his fat ass up. But I never threatened him' This nurse informed resident that the phone conversation that roommate is having has nothing to do with [Resident #3]. [Resident #3] states 'well, I am sick of him lying all the time.' [Resident #3] was assisted in getting dressed and was taken from room. Roommate called police department over altercation, officer was dispatched, where it was determined that no offense occurred. Administrator notified of situation. Record review of nursing progress notes, dated 4/14/2025 at 11:30 AM, written by the SW, indicated: Spoke to [Resident #3] regarding an altercation he had with his roommate. [Resident #3] stated he 'didn't meant to holler' towards roommate and that his roommate 'lies to people' on the phone all the time. Educated [Resident #3] that he did not need to intervene in other resident's business. Educated resident that if he had any concerns to come to staff - [Resident #3] understood that hollering towards resident was inappropriate and that he would not do that again. [Resident #3] agreed to room change as well. 2. Record review of the electronic face sheet for Resident #4 indicated Resident #4 admitted to the facility on [DATE] with the most recent admission on 3/27/2025 with diagnosis that included: vascular dementia (difficulty thinking, memory and behavior), Hemiplegia (paralysis on the left side of the body), and muscle weakness. Record review of Resident #4's admission MDS assessment dated [DATE] indicated a BIMS of 13, which indicates no cognitive impairment. It also indicated Resident #4 was independent with walking 150 feet. Record review of Resident #4's care plan dated 11/15/2024 indicated: I have a ADL self-care performance deficits related to disease processes. I am mostly independent with ADLs with some assistance with set-up and supervision with locating thing. I have left side hemiplegia and walk with a cane. Interventions included: 1. Transfer: The resident requires supervision and set-up assistance by 1 staff to move between surfaces as necessary. Record review of facility incident report for Resident #4 dated 11/30/2024 at 6:45pm indicated: Resident stated he was outside smoking when he and another male resident started arguing, he stated he walked up to the other resident and the other resident pulled himself up out of his wheelchair using him they began hitting one another and fell to the ground. The notes section indicated: Resident involved in physical altercation with [Resident #3]. Resident had words with other resident and both decided to show who was boss. Few slaps back and forth, easily redirected by staff present. No injury noted or complaint of pain. Both residents redirected to their room and further smoke breaks this evening. Record review of facility progress note for Resident #4 dated 11/30/2024 at 7:31pm completed by the LVN C indicated: This nurse was at the medication cart when a dietary worker came in the hallway and stated hey they need some help out here. Nurse went to the dining room and the door leading out to the smoke area was open. Resident was observed laying in the smoke area with the other male resident beside him and they were both arguing and still trying to engage physically. Nurse stepped between them and assisted this resident up. Resident was assisted back in the facility and sat in a chair. After he got his shoes back on he was assisted to his room. Resident described in his words what happened. DON was notified. Resident was instructed to stay away from the other male resident and there would be no other smoke breaks for him. Resident did not have any visible physical injuries after assessment. Denies any physical or emotional distress. 3. Record review of the electronic face sheet for Resident #5 indicated Resident #5 admitted to the facility on [DATE] with diagnosis that included: toxic encephalopathy (brain disorder caused by exposure to toxic substances), chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe), type 2 diabetes (high blood sugar). Record review of Resident #5's quarterly MDS assessment dated [DATE] indicated a BIMS of 14, which indicates no cognitive impairment. It also indicated Resident #2 was independent with walking 150 feet. Record review of Resident #5's care plan dated 2/21/2025 indicated: The resident was/has potential to be physically aggressive hit another resident with walker, related to anger, poor impulse control 2/15/25-became impatient with another resident and hit that resident with walker. Interventions included: 1. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document . 3. Monitor/document/report PRN any s/sx of resident posing danger to self and others. 4. Offer psych or psychology services as needed. 5. Social Worker to talk and evaluate resident after any incidents. 6. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Record review of facility progress notes for Resident #5 dated 2/15/2025 at 3:16pm completed by the LVN A indicated: Resident had an witnessed physical altercation with another resident. Resident was found sitting on the floor in front of his walker. Resident denies pain or discomfort at this time. Resident vital signs are stable. No injuries noted at this time. 4. Record review of the electronic face sheet for Resident #6 indicated Resident #6 admitted to the facility on [DATE] with diagnosis that included: intracerebral hemorrhage (stroke), Hemiplegia (paralysis on the right side of the body), and muscle weakness. Record review of Resident #6's annual MDS assessment dated [DATE] indicated a BIMS of 03, which indicates severe cognitive impairment. It also indicated Resident #6 required substantial to maximal assistance with transfers. Record review of Resident #6's care plan dated 1/5/2025 indicated: I received physical and verbal aggression from another resident when he was grabbed by the hand and another resident told him he would knock the hell out of him. I am still protective of other residents and may act aggressively towards others. Interventions included: 1. Resident will be assessed for emotional distress and physical injuries after incident and as needed. 2. Resident will be redirected when appropriate. 3. Resident will not go on the same smoke breaks as physically aggressive resident . 5. Staff will monitor for safe environment and to ensure no unusual episodes occur. Record review of facility incident report for Resident #6 dated 1/5/2025 at 8:30am indicated: Resident was in dining room near the smoking door with another resident when his w/c bumped into the other resident's chair. The other resident grabbed his and and told him if he did it again he would knock the shit out of him. Residents were separated and no further physical contact was made. Resident was assessed for injuries with none observed. Resident showed no signs of emotional trauma. Residents will not go on the same smoke breaks together. 5. Record review of the electronic face sheet for Resident #7 indicated Resident #7 admitted to the facility on [DATE] with the most recent admission on 10/31/2022 with diagnosis that included: major depressive disorder (persistently low mood), chronic respiratory failure with hypoxia (lungs cannot adequately provide oxygen to the blood), and muscle weakness. Record review of Resident #7's quarterly MDS assessment dated [DATE] indicated a BIMS of 15, which indicates no cognitive impairment. It also indicated Resident #4 required supervision or touching assistance with walking 150 feet. Record review of Resident #7's care plan dated 4/15/2022 indicated: I may have a potential for Coping Impaired related to situational and social factors including loss of autonomy or independence; disrupted family life, grief, loneliness, helplessness, or hopelessness. I am seeing counselor at facility and have visits with [Psychiatrist] as needed. Interventions included: Monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. During an interview on 4/15/2025 at 10:48am Resident #5 said Resident #3 was in the way while he was trying to get out the door to the smoking area. He said he asked him to let him get by and he said Resident #3 talked noise and cussed him out. He said Resident #3 was agitated and speaking in Spanish. He said Resident #3 turned around and was raising up out of his chair like he was going to fight. He said he then hit him with his walker. He said they both fell on the floor in the dining room. He said Resident #3 called the police and they came and talked to him and told him the next time they would take him to jail. He said if Resident #3 acted that way again he would hit him again. He said that had been the only physical incident he had with Resident #3. He said there was another guy on the 300 hall Resident #4 that had a physical altercation with Resident #3. He said Resident #3 had problems with a lot of residents because he was always in other peoples business and cussing other residents. During an interview on 4/15/2025 at 11:11am Resident #7 Said she calls bingo when the activity director can't and said Resident #3 yells out at her when she calls bingo like a bully would. She said they sent Resident #3 to a behavioral hospital because he was physical with Resident #6. She said they initially put Resident #3 on another hall, but he is now back on her hall. She said Resident #3 will throw things. She said Resident #6 is really the only resident she had ever seen Resident #3 kick or get physical with. She said he kissed the older ladies' hands a lot and did not feel it was appropriate. She said one lady (unknown) finally yelled at him to stop and leave her alone. She said Resident #3 did a lot of cussing and calling people names. She said Resident #3 had asked her for sex, and she turned him down and he didn't like it. She said he asked a lot of the ladies and employees for sex. She said she was not afraid of him physically, but she was afraid of what he brought out in her and was afraid she would hit him. She said one time they got in an argument, and he tried to charge at her, and staff pulled him back. She said she felt so much better when he resided on a different hallway. She said he had just moved back to this hall yesterday 4/14/2025 because he got into an altercation with his roommate on the 300 hall and his roommate called the police. She said all altercations or arguments is always centered around Resident #3. During an interview on 4/15/2025 at 11:25am Resident #6 could not answer questions due to diagnosis of aphasia (language disorder that results from damage to the brain's language centers). During an interview on 4/15/2025 at 11:31am CNA D said Resident #3 moved back to the 500 hall yesterday 4/14/2025. She said she did not know what prompted the move back to the 500 hall. She said Resident #3 was smart mouthed and disrespectful to staff and residents. She said a staff member would be talking to another resident and Resident #3 will chime in with his negative input. She said she had seen the arguing with Resident #3 but had never seen him get physical with anyone. During an interview on 4/15/2025 at 12:52pm the ADON said he was an instigator and liked to create tiffs until other residents go off on him. She she had been employed at the facility since December 2024, Resident #3 had been sent to a behavioral hospital and had 2 room changes, and medication changes. She said the SW had been sending out referrals to discharge Resident #3, but no one would accept him. During an interview on 4/15/2025 at 1:13pm the DON said Resident #3 liked to stir the pot and instigate arguments with residents and staff. She said Resident #3 had been in a group home and multiple nursing homes prior to being at the facility. She said Resident #3 had issues when he was living at home with his mother and thought that APS had been involved because Resident #3 had acted out and called the police many times while he was there. She said Resident #3 was sent to Brentwood after he kicked Resident #6 at breakfast. During an interview on 4/16/2025 at 10:01am the SW said on 3/25/25 Resident #3 kicked Resident #6 during breakfast because he was making some noise and Resident #3 did not like it. She said he came to her office that morning and said he had kicked Resident #6 but did not know why he did it. She said on 2/15/25 the residents were going out to smoke and Resident #3 was in the doorway and Resident #5 was telling him to go go go and he said he couldn't go so he was cussing Resident #5 and Resident #5 picked up his walker and hit Resident #3 and both residents began fighting and fell on the floor. She said Resident #3's head was sore from being hit and he had an abrasion but otherwise there were no other injuries. She said she saw the video footage and could not tell if Resident #3 was hit on the head or shoulder area. She said on 11/30/2024 Resident #3 and Resident #4 were outside in the smoking area and were going back and forth arguing and both residents ended up on the ground. She said she couldn't remember if either one actually hit the other one. She said she couldn't remember any other physical altercations that she was aware of. She said Resident #3 was referred to counseling services on 11/5/24 but refused. She said on 2/19/25 the order and consent were received for counseling services, and he was evaluated by the counselor on 2/26/25. She said he had a verbal altercation a few days earlier and if another incident happened then they needed to seek further help for him. She said the Resident #3 received counseling services on Wednesday and the Psych MD and sees him monthly. She said she sent out 6 referrals to seek alternate placement for Resident #3 between 4/1/2025 and 4/15/2025 and all had been denied. During an interview on 4/16/2025 at 11:50am the Administrator said had a history of behaviors. She said she knew that the Resident #3 had behaviors before Resident #3 admitted to the facility, but she accepted him anyway because she felt like they could help Resident #3. She said Resident #3 liked to instigate and stir the pot with other residents and staff. She said Resident #3 often inserted himself into conversations with staff and residents that were not about him. She said Resident #3 knew what he was doing and would often apologize after an altercation with staff or other residents. During an interview on 4/16/2025 at 1:21pm Resident #3 said when he was 28 he was in the hospital for 2 months and that's when he was diagnosed with the Wilson's disease. He said he is a sweet guy but when you him make him mad, he turns into the devil. He said he did not receive counseling services at the facility. He said he had only talked to a counselor 1 time since he had been at the facility. He said when he has the incidents with other residents he will go an apologize after the incident was over. He said he did not have control over his actions when he gets mad and he gets anxious. He said he told Resident #4 to tie his shoe and Resident #4 told him to shut up and for him to tie it and said he got up and started walking over to him and they just began fighting and fell to the ground in the smoking area. He said Resident #5 told him to go out the door and he said Resident #5 took his walker and put it over his head and jerked it back as if to choke him. He said he kicked Resident #6 because he was jealous the staff were feeding Resident #6 and not him. He said he went to the behavior hospital after he kicked Resident #6. He said he got kicked out of another nursing facility for trying to bite the medication aide's finger. During an interview on 4/17/2025 at 1:25pm Resident #4 said he did not like Resident #3 and said on the day in question he was in the smoking area. He said Resident #3 told him his shoe was untied and he told Resident #3 it was none of his business. He said Resident #3 would not leave him alone and he got mad and him and Resident #3 mutually began fighting and fell on the ground. He said after the incident he did not like Resident #3 but he just tried to stay away from him and stay out of trouble. During an interview on 4/22/2025 at 9:28am LVN A said on 2/15/2025 someone came and got her and let her know Resident #3 and Resident #5 were fighting in the kitchen. She said Resident #5 told her that Resident #3 was talking bad to him. She said Resident #5 said he hit him. She said when she asked Resident #3 what happened he said Resident #5 was talking to someone else and Resident #3 got in their business and started the argument with Resident #5. She said both residents fell on the floor in the dining room. She said Resident #3 was always in someone else's business. She said she thought Resident #3 was just angry because he was in the nursing home. She said Resident #3 would wake up and just be mad at the world. During an interview on 4/22/2025 at 10:14am CNA E said on 2/15/2025 she was taking the smokers out and was standing in the doorway. She said she heard Resident #5 tell Resident #3 to go and he said don't you see CNA E in the way. She said she didn't hear him say anything else and then Resident #5 put his walker over Resident #3 like he was trying to choke him with it. She said then Resident #3 started shaking and fell on the floor. She said Resident #3 called the police. Said she thought both residents had been arguing prior to the incident. She said Resident #3 could not get along with anyone. Record review of the facility's policy titled Abuse, dated 2/1/2017, reflected: . Residents will not be subjected to abuse by anyone, including, but not limited to community staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, care taker, friends, or other individuals .Upon notification of an allegation of physical or mental abuse, neglect or involuntary seclusion, the facility will conduct interviews that include documented statement summaries from the alleged perpetrator, the alleged victim, family members, visitors who may have made observations, roommate, and any staff who worked prior to and during the time of the incident. Investigations will focus on determining if the abuse occurred, the extent of the abuse and potential causes . This was determined to be an Immediate Jeopardy (IJ) on 04/16/2025 at 5:42 PM. The facility Administrator was notified. The Administrator was provided with the IJ template on 4/16/2025 at 5:42 PM. The following Plan of Removal submitted by the facility was accepted on 4/17/2025 at 2:07 PM: The following is a plan of removal, which has been immediately implemented , to remedy the immediate jeopardy as a result of alleged deficient practices, which was imposed on April 16, 2025 at 5:45pm. F610 Investigate/Prevent/Correct Alleged Violation 11-30-24: Resident #3 was assessed on 11-30-24 after incident and had scratches to left arm that were treated in house. Resident #4 was assessed on 11-30-24 after incident and had no injuries or physical or emotional distress. DCO and LVNs redirected residents to their rooms and with no further smoke breaks for them that evening. Psych Services conducted a patient care call with Resident #3 on 12-2-24 with a new order for an increase to his Depakote ER to 1500 mg qhs. Psych Services conducted a patient care call with Resident #4 on 12-2-24 with no new orders. 2-15-25: Resident #3 was assessed on 2-15-25 after incident and had a small abrasion to right midback. Resident #5 was assessed on 2-15-25 after the incident and had no injuries. Police were called and they came and spoke to both residents and left. DRSS spoke with both residents individually on 2-17-25, and they reported no emotional effects from the incident and both residents were offered counseling services, which were refused. Psych services conducted a patient follow up visit on 2-18-25 on Resident #3 with no new orders or interventions. Resident #3 was reeducated on counseling services on 2-19-25 and agreed to the service and signed consent for treatment. Resident #5 refused counseling services again on 2-18-25. 3-25-25: Resident #3 was discharged to Behavioral Hospital on 3-25-25 for behaviors. Resident #6 was assessed on 3-25-25 after the incident with no injuries. Psych Services visited Resident #6 on 3-29-25 with no new orders. Immediate Action All staff in-serviced on April 16, 2025 by Executive Director of Operations (EDO)/Director of Clinical Operations(DCO) and/or designee on the following topics: Prevention, Identification and Reporting/Investigation of Abuse. All staff not present at time of in-service will not be permitted back to work until in-service is complete. The EDO/DCO were in-serviced on 4-16-25 by the RDCO on Prevention, Identification and Reporting/Investigation of Abuse. 4-16-25: Resident #3 was placed on one-to-one monitoring at 7:20pm. Discharge Planning initiated to family. Family agreed by phone to discharge resident to their care on 4-16-25 at 9pm. Resident remained on one-to-one monitoring until discharge on [DATE] at 7:52am. 4-16-25: Safe Surveys were conducted by DRSS and/or designee with all residents cognitively able to participate. Results of and action after Safe Surveys are as follows: 3 residents expressed that Resident #3 was rude- Resident #3 was on one-on-one monitoring, 1 resident expressed that a nurse was unsure of what to do for his wound care-resident no longer in facility, 1 resident expressed a CNA was rough during her bed bath-the resident was reinterviewed by DCO to get details, the resident did not think the CNA had been abusive or intentionally rough, it was determined that due to her current clinical condition she requires 2 person assistance for bed mobility and personal care, the care plan and tasks were updated on 4-17-25, One-on-one in-service to be completed on 4-17-25 with CNA. 4-17-25: All residents identified as at risk for physically aggressive behaviors were reviewed by the CRC/ADCO to ensure they had an accurate care plan, appropriate interventions and appropriate Psych Services or Counseling Services The DCO/ADCO/EDO will monitor EMR documentation including the 24-hour report, incident reports and alerts, and Grievances to identify potential abuse or situations requiring further investigation during morning meeting. Abuse allegations will be reported and investigated according to company policy and THHS regulations. Potential abuse or situations requiring further investigation will be documented on a Grievance form with

Based on observation, interview, and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 7 (Resident #1 and Resident #2) residents reviewed for supervision. The facility failed to ensure the secured unit courtyard gates were locked after lawn care services on [DATE]. On [DATE] Resident #1 eloped from the facility grounds through an unlocked gate in the courtyard of the secured unit. A good Samaritan encountered Resident #1 at a nearby doctor's office and Resident #1 was returned to the facility. The facility failed to provide adequate supervision for Resident #2. On [DATE] Resident #2 eloped from the facility through the front door. A good Samaritan encountered Resident #2 at a nearby roadway intersection and returned Resident #2 to the facility. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:51 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm because (e.g.) all staff had not been trained on the facilities elopement policy. This failure could place residents at risk of not being properly supervised resulting in injury or death. Findings included: 1.Record review of the electronic face sheet for Resident #1 indicated Resident #1 admitted to the facility on [DATE] with diagnosis that included: dementia (decline in cognitive function), muscle weakness, type 2 diabetes (high blood sugar). Record review of Resident #1's annual MDS assessment dated [DATE] indicated a BIMS of 03, which indicates severe cognitive impairment. It also indicated Resident #1 was independent with walking 150 feet. Record review of Resident #1's care plan dated [DATE] indicated: I am exhibiting behavior of wandering. I have dementia and may wander or pace. I may enter other's rooms uninvited. I respond well to redirection at this time. I have been moved to secured unit for safety. Interventions included: Staff will monitor for safe environment and to ensure no unusual episodes occur. Record review of Resident #1's elopement risk assessment dated [DATE] indicated an elopement score of 15 which was of high risk category. Record review of Resident #1's elopement risk assessment dated [DATE] indicated an elopement score of 3 which was of medium risk category. Record review of facility incident report for Resident #1 dated [DATE] at 3:31pm completed by the DON indicated: Resident had finished eating lunch and asked to go outside in the courtyard, approximately, 12:55pm. At 1:08pm a family member of a staff member, [family member] called facility asking if we were missing one of our residents. Staff immediately left facility, where [family member] had resident and brought him back to facility at approximately 1:13pm just smiling. When SW interviewed resident, he remembers leaving facility on foot but doesn't know where he was going. 2. Record review of the electronic face sheet for Resident #2 indicated Resident #2 admitted to the facility on [DATE] with diagnosis that included: anxiety (feelings of worry or unease), metabolic encephalopathy (brain dysfunction), type 2 diabetes (high blood sugar). Record review of Resident #2's admission MDS assessment dated [DATE] indicated a BIMS of 01, which indicates severe cognitive impairment. It also indicated Resident #2 partial to moderate assistance with walking 150 feet. Record review of Resident #2's care plan dated [DATE] indicated: I will reside on the facility secured care unit due to wander/elopement risks. Related to disoriented to place, history of attempts to leave facility unattended, impaired safety awareness. Interventions included: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Record review of Resident #2's elopement risk assessment dated [DATE] indicated an elopement score of 3 which was of medium risk category. Record review of Resident #2's elopement risk assessment dated [DATE] indicated an elopement score of 9 which was of high risk category. Record review of facility incident report for Resident #2 dated [DATE] at 8:30am completed by the ADON indicated: A community member knocked on front entrance door with resident noted to be sitting in wheelchair, stating he was down there in the road Resident assessed with no noted distress. Resident #2 said I just want to go home. Record review of facility incident report for Resident #2 dated [DATE] at 8:30am notes completed by the DON indicated: from review of cameras-resident left building behind [family member] family member who did not close the door after him. Per staff-they saw resident on 400 hall approximately, 8 am as they went into a staff meeting, when they came out at approximately 8:10 he was out of facility and in process of being returned. Record review of Resident #2's electronic medical record indicated Resident #2 expired in the facility on [DATE]. During an interview on [DATE] at 11:44am CNA Q said they document once a shift to check the outside doors and gates to make sure they are locked. She said for the back door you have to put in the door code and that unlocks the door and the outside gate. She said you have to be fast to go down to the gate because it locks back pretty fast. She said the dining room door is unlocked and residents can come and go as they want. She said they have to push the emergency exit button that unlocks all doors in the secured unit to unlock the gate in the dining room courtyard. She said they have to push and turn the emergency exit button again to lock the gate back. She said when the [NAME] come the button releases the gate and one of them goes and opens the gate and then the other pushes the button to lock all the doors back. She said when the lawn care service was at the facility, they had to watch the residents in the secure unit to ensure no one got out of the locked doors. She said the staff had to remember to relock the doors and gates after the lawn care service was finished. During and observation and interview on [DATE] at 11:44am CNA R said that all gates are checked once a shift and CNA Q usually already checked them prior to him getting to work so he typically did not check them. CNA R put in the code on the back door of the secured unit. CNA R said the code would release the back door and also the gate outside of the back hallway door. Surveyor observed the gate being released and the gate required being pushed back so the magnets on the gate would reattach and lock the gate. If the gate was not pushed back together the gate would not lock. The secured unit dining room door was observed with no lock and residents could come and go freely to the outside courtyard. CNA Q pushed the emergency exit button which then released all locked doors of the secured unit. CNA Q then pushed and turned the emergency exit button in the dining room to relock the secured unit doors and gates. The Surveyor observed the courtyard gate had to be physically pushed back together in order for the magnets to reattach and lock the gate. Resident #1 was sitting outside during this observation and got up and went and checked to see if the gate was locked. CNA R said they had to keep a closer watch on the residents when the lawn care service was there and then had to remember to relock the doors and gates once they were finished. During an interview on [DATE] at 12:52pm the ADON said she started in [DATE] right before the Resident #2's elopement. She said a passerby came and knocked on the door and said Resident #2 was out and had brought him back to the door. She said she didn't know where she had encountered Resident #2 and did not have contact with anyone at the facility and was just driving by. She said they took Resident #2 to the unit and assessed Resident #2 and then checked the door locks and alarms. She said she saw Resident #2 at around 8:00am and she didn't know how long Resident #2 was out before being brought back to the facility. During an interview on [DATE] at 1:13pm the DON said Resident #1 got out the gate and went to a nearby doctor's office. She said Resident #1 was brought back to the facility at 1:13pm. She said at 12:55pm Resident #1 was last seen after he had just finished lunch and then was returned to the facility at 1:13pm. She said they believed there was an issue with the magnetic lock but when the lock was checked it was fine. She said the lawn care service had been there the day before but is not sure if that was the cause. She said staff were supposed to do 4-hour checks on the gates that was started prior to the elopement. She said they had a monitoring sheet for the gate checks but was not able to find any monitoring sheets since [DATE]. She said Resident #2 admitted on [DATE] and eloped on [DATE]. She said Resident #2 went to the door and wheeled out the door right behind another family member. She said a passerby brought the resident back from down the street on the corner at the redlight. She said Resident #2 went out at 8:10am and was brought back to the facility at 8:26am. During an interview on [DATE] at 9:28am LVN A said she was here the day Resident #2 eloped but said all she remembered was that Resident #2 kept saying he wanted to go home. She said Resident #2 kept going to the doors trying to get out and someone would redirect him and then he eloped. During an interview on [DATE] at 9:50am LVN H said Resident #1 had gotten out of the secured unit before the elopement. He said Resident #1 liked standing by the doors and one day he didn't close the door soon enough and Resident #1 got out of the secured unit and was walking around the nurse's station. He said he had eyes on Resident #1 the whole time and was easy to get back into the secured unit. He said he didn't remember the day he got out of the gate. He said he was here the day Resident #2 eloped but by the time he knew anything about it they had already gotten Resident #2 back in the facility. During an interview on [DATE] at 10:48am with the Administrator via phone, she said her expectation was to prevent elopements. She said if a resident were to elope that resident was in danger of being hurt. Record review of the facilities Elopement policy dated [DATE] indicated: 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 . This was determined to be an Immediate Jeopardy (IJ) on [Date] at [Time]. The [Titles of people identified] were notified. The [Name of person given the IJ template] was provide with the IJ template on [Date] at [Time]. I . The facility's plan of removal was accepted on [DATE] at 9:16 am and included: 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 [DATE] at 5:26pm. Resident #1 was assessed and interviewed upon return on [DATE]. The resident was not injured and was not in distress. The Maintenance Director checked the functioning of the magnetic locks on the doors and gates on the secured unit, all were in working order. Secured Unit staff were educated on [DATE] on the required gate lock checks every 4 hours and to complete the Secured Unit Gate Monitoring Log. Resident #2 was assessed upon return on [DATE]. The resident was not injured and was not in distress. The Maintenance Director and EDO checked all exit doors for functioning of key pads and alarms, all were in working order. Video footage revealed the resident exited the front door behind another resident's family member. The resident was moved to the secured unit due to the new elopement risk on [DATE]. The front door code was changed on [DATE], and a staff in-service was completed on [DATE] on keeping the code confidential. All staff in-serviced on Elopement/Missing Resident on [DATE] by Executive Director of Operations (EDO)/Director of Clinical Operations(DCO) and/or designee. 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 magnetic lock reset function during power disruption on [DATE] by EDO and DCO. All staff not present at time of in-service will not be permitted back to work until in-service and competency test is complete. implemented and educated all staff on new process during lawn care services on [DATE]. New process adopted by facility is as follows: Facility staff will bring residents inside during lawn care and monitor all exit doors to not allow residents to leave secured unit hallway. Staff will then reengage the magnetic locks when lawncare is completed and verify that each door and gate are secured. Lawn vendor contacted on [DATE] at 8:45 pm by EDO and educated on communication with EDO and/or DCO about exiting the property and verifying the gate is secured. All staff in-serviced on facility door code confidentiality and who to contact if he/she feels the code has been compromised on [DATE] by EDO and DCO. All staff not present at time of in-service will not be permitted back to work until in-service is completed. Facility EDO reviewed and in-serviced on facility policy to door code changes. All resident with risk of elopement have the potential to be affected by the this alleged deficient practice. An audit was completed on [DATE] by the CRC to ensure all residents had a current elopement risk assessment and accurate care plan. The Medical Director was initially made aware on [DATE] of the immediate jeopardy, and has been involved in the development of the plan to remove during an abbreviated QA. These conversations are considered a part of the QA process. Next schedule QA meeting set for [DATE] at 12pm. All in-servicing began [DATE]. This plan was initially implemented [DATE] and will be monitored, through personal observation, through completion by Regional [NAME] President of Operation and Regional Director of Clinical Services. On [DATE] the Surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of skin assessment completed [DATE] on Resident #1. Record review of inservice record dated [DATE] regarding required gate lock checks on secured unit every 4 hours and check the courtyard gate to ensure the lock is secure and complete the log attached. 18 staff signatures on inservice. Record review confirmed Resident #2 was moved to the secured unit on [DATE]. Record review of an untitled document dated [DATE] revealed maintenance director and ADO together checked all exit doors for functioning of keypads and alarms, and all were in working order. Record review of inservice record dated [DATE] titled Do not give the door codes to anyone other than staff. Staff are to let visitors out of the doors. 34 staff signatures on inservice. Record review of inservice dated [DATE] at 7:00pm titled 1. All staff inservices on the elopement/missing resident protocol. With 33 employee signatures. Record review of inservice dated [DATE] at 7:00pm titled 2. All staff inservices on the magnetic lock reset function. 3. All staff inservices on process during lawn care visits. With 33 employee signatures. Record review of inservice dated [DATE] at 8:45pm titled Lawn vendors to communicate with ADM/DCO each time they need to enter and exit the secured unit patio/lawn care areas. Doors and Gates must be secured before they leave the area lawn care service inserviced via phone. Record review of inservice dated [DATE] at 7:00pm titled 4. Door codes-are confidential and are never to be given to residents/family members or vendors at any time With 33 employee signatures. Record review of residents with risk of elopement audit completed by the CRC on [DATE]. Record review of Ad Hoc Qapi meeting held on [DATE] at 7:15pm attended by the medical director, Administrator and DON. During interviews conducted on [DATE] between 8:45 am - 9:15 am CNA M, PTA, CNA B, CNA F, CNA N, Activity Director, HSK, Floor Tech, Laundry U, Laundry V, Receptionist, BOM, CNA K, ADON, CNA S, LVN H, LVN T, LVN A, and LVN G all verbalized if a resident is missing a code pink is called. They all said the codes to the doors are never to be shared with visitors and if a visitor is observed entering a code the Administrator was to be notified so it can be changed. They all said the gates on the unit must be checked every 4 hours and the inside buttons to be checked to make sure the light was green. They said if the lawn care service was present, they were to be let in and then back out when they were finished. On [DATE] at 9:55am, the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a level of no actual harm with the potential for more than minimal harm with a scope identified as isolated due to the facility's need to monitor the implementation and effectiveness of its POR.

Based on observation, interview, and record review, the facility failed to provide an effective pest control program to ensure the facility is free of pests and rodents in 1 of 1 facility kitchens. The facility failed to address the roaches in the facility kitchen, which staff was aware of and had reported to the Dietary Manager and ADM. This failure could place all residents who eat meals prepared in the facility kitchen at risk of food borne illness and cross contamination. Findings included: An observation on 4/17/25 at 12:30 p.m. in the facility kitchen revealed dead insects on top of dry-food storage shelves and stuck to the walls below a food preparation area. During an interview on 4/17/2025 at 12:40 p.m., the Dietary Aide said there had been roaches in the kitchen for at least a month. She said had reported the roaches to the Dietary Manager and ADM, but the issue had not been addressed. During an interview on 4/17/2025 at 12:45 p.m., the [NAME] said there had been roaches in the kitchen off and on since December of 2024. She said she had reported the issue to both Dietary Manager and ADM but there were still roaches in the kitchen. During an interview on 4/17/2025 at 1:00 p.m., the Dietary Manager said she had worked at the facility for 4 months and there had been an issue with roaches in the facility kitchen. She said pest control had come out today to spray for pests. During an interview on 4/17/25 at 2:00 p.m., the ADM said the facility had roaches in the walls in the kitchen since December of 2024. She said facility maintenance staff saw roaches in the walls in the kitchen while repairing a leak on or around 4/11/25. She said facility staff sprayed the area with a can of pesticide, but she did not call pest control because they were coming out next week for a scheduled monthly visit. She said there was no risk to residents from roaches in the kitchen. Review of the Pest Control service visits revealed a Service Order for a visit on 4/16/25. The service order instructions indicated there were reports of roaches in the dining room cabinets and kitchen. Pest control products were applied in the kitchen, dish pit, dining room, break room, and common area targeting pests American Roaches and German Roaches with a follow-up visit recommended to be scheduled in a week. Review of a facility policy titled Pest Control last revised in May 2008 indicated .This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .

Based on observations, interviews, and record review, the facility failed ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 8 residents (Resident #8) reviewed for accomodation of needs. The facility failed to ensure Resident #8's call light in the room was left within reach on 4/17/2024. This failure could place residents at risk of injury, pain, hospitalization , and a diminished quality of life. Findings included: Record review of an Admission Record dated 4/17/2025 for Resident #8 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of dementia (altered cognition) and secondary diagnoses of hemiplegia and hemiparesis (weakness or paralysis on one side of the body) and muscle weakness. Record review of an MDS assessment dated [DATE] for Resident #8 indicated he had a BIMS score of 12 which indicated moderate cognitive impairment. He was dependent on staff for most ADLs except for eating. He was always incontinent of bladder and had an ostomy. Record review of Resident #8's care plan dated 4/5/22 and revised on 2/25/24 indicated he had a history of falls and was at risk for future falls due to diagnosis of hemiplegia/hemiparesis. An intervention was in place to Ensure call light is in reach and answer promptly. During an observation and interview on 4/17/25 at 11:00 AM, Resident #8 was in his room lying in his bed in a semi-private room with no roommate. His call light was lying on the unoccupied bed in the room. Resident #8 said CNA B assisted him with personal care and left his call light lying out of reach. He said he used a trapeze bar (bed pull up assistance device) to sit up in bed and could not stand or walk independently. During an interview on 4/17/2025 at 11:30 AM, CNA B said she was assigned to hall 500 today, 4/17/2025, where Resident #8 resided. CNA B said she had recently rounded on Resident #8 and assisted him with personal care. She said CNAs were responsible for ensuring call lights were left accessible to residents before leaving the room. During an interview on 4/17/25 at 2:00 PM, the ADM said direct care staff were expected to round on every resident at least every two hours. She said direct care staff were expected to ensure call lights were left within reach before leaving the room. The ADM said the DON was responsible for ensuring all nursing staff and CNAs received required training and successfully completed skill competency checkoffs. During an interview on 4/17/2025 at 2:45 PM, the DON said she was responsible ensuring all CNAs and nursing staff successfully complete competency checkoffs. She said CNAs and nurses were expected to ensure call lights were accessible by residents before leaving the room. Record review of a facility policy titled Bedrooms revised in May 2017 indicated .All resident rooms are equipped with a resident call system that allows residents to call for staff assistance .

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, which included to the State Survey Agency, in accordance with State law through established procedures for 3 of 7 residents (Resident #3, Resident #4 and Resident #6) reviewed for abuse. 1. The facility failed to immediately report an allegation of resident-to-resident abuse to HHSC after the allegation was made on 11/30/2024. On 11/30/2024 at 6:45 PM Resident #4 and Resident #3 had a physical altercation while outside in the smoking area. 2. The facility failed to report immediately report an allegation of resident-to-resident abuse to HHSC after the allegation was made on 3/25/2025 at 8:09 AM. On 3/25/2025 Resident #3 kicked Resident #6 multiple times during breakfast. These failures could place residents at risk of further potential abuse. Findings include: 1. Record review of the electronic face sheet for Resident #3 indicated Resident #3 admitted to the facility on [DATE] with the most recent readmission on 4/2/2025 with diagnosis that included: bipolar disorder (significant shifts in mood, energy, and activity levels, causing periods of intense highs and lows), impulse disorder (difficulty controlling impulses, urges, or behaviors, leading to harmful or inappropriate actions), parkinsons (neurological disorder that primarily affects movement), wilsons disease (causes copper to build up in the liver, brain, and other organs). Record review of Resident #3's admission MDS assessment dated [DATE] indicated a BIMS of 15, which indicates no cognitive impairment. Record review of Resident #3's care plan dated 11/15/2024 indicated: I am exhibiting behavior of making flirtatious comments towards staff and some female residents. Interventions included: 1. [Counseling] services evaluate and treat. 2. Monitor/document/report PRN any signs/symptoms of resident posing danger to self and others. 3. Staff will monitor for safe environment and to ensure no unusual episodes occur. The care plan dated 3/4/2025 indicated I am exhibiting behavior of-verbal aggression to other residents, I like to stir the pot, boss people around and tell people what they can and can't do. I am often loud and obnoxious and often instigate arguments with staff and residents. Interventions included: 1. Monitor/document/report PRN and signs/symptoms of resident posing danger to self and others. 2. Psychological services evaluate and treat. 3. Staff will monitor for safe environment and to ensure no unusual episodes occur. 4. When the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away and approach later. Record review of nursing progress notes, dated 3/25/2025 at 8:09 AM, written by the LVN A, indicated: It was reported to this nurse that [Resident #3] kicked another resident for no reason this morning at breakfast time. CNA E was feeding another resident and [Resident #3] decided to kick him multiple times. Resident is aware of possible consequences of his actions. Notified [DON]. 2. Record review of the electronic face sheet for Resident #4 indicated Resident #4 admitted to the facility on [DATE] with the most recent admission on 3/27/2025 with diagnosis that included: vascular dementia (difficulty thinking, memory and behavior), Hemiplegia (paralysis on the left side of the body), and muscle weakness. Record review of Resident #4's admission MDS assessment dated [DATE] indicated a BIMS of 13, which indicates no cognitive impairment. It also indicated Resident #4 was independent with walking 150 feet. Record review of Resident #4's care plan dated 11/15/2024 indicated: I have a ADL self-care performance deficits related to disease processes. I am mostly independent with ADLs with some assistance with set-up and supervision with locating thing. I have left side hemiplegia and walk with a cane. Interventions included: 1. Transfer: The resident requires supervision and set-up assistance by 1 staff to move between surfaces as necessary. Record review of facility incident report for Resident #4 dated 11/30/2024 at 6:45pm indicated: Resident stated he was outside smoking when he and another male resident started arguing, he stated he walked up to the other resident and the other resident pulled himself up out of his wheelchair using him they began hitting one another and fell to the ground. The notes section indicated: Resident involved in physical altercation with [Resident #3]. Resident had words with another resident and both decided to show who was boss. Few slaps back and forth, easily redirected by staff present. No injury noted or complaint of pain. Both residents redirected to their room and further smoke breaks this evening. Record review of facility progress note for Resident #4 dated 11/30/2024 at 7:31pm completed by the LVN C indicated: This nurse was at the medication cart when a dietary worker came in the hallway and stated, hey they need some help out here. Nurse went to the dining room and the door leading out to the smoke area was open. Resident was observed laying in the smoke area with the other male resident beside him and they were both arguing and still trying to engage physically. Nurse stepped between them and assisted this resident up. Resident was assisted back in the facility and sat in a chair. After he got his shoes back on he was assisted to his room. Resident described in his words what happened. DON was notified. Resident was instructed to stay away from the other male resident and there would be no other smoke breaks for him. Resident did not have any visible physical injuries after assessment. Denies any physical or emotional distress. 3. Record review of the electronic face sheet for Resident #6 indicated Resident #6 admitted to the facility on [DATE] with diagnosis that included: intracerebral hemorrhage (stroke), Hemiplegia (paralysis on the right side of the body), and muscle weakness. Record review of Resident #6's annual MDS assessment dated [DATE] indicated a BIMS of 03, which indicates severe cognitive impairment. It also indicated Resident #6 required substantial to maximal assistance with transfers. Record review of Resident #6's care plan dated 1/5/2025 indicated: I received physical and verbal aggression from another resident when he was grabbed by the hand and another resident told him he would knock the hell out of him. I am still protective of other residents and may act aggressively towards others. Interventions included: 1. Resident will be assessed for emotional distress and physical injuries after incident and as needed. 2. Resident will be redirected when appropriate. 3. Resident will not go on the same smoke breaks as physically aggressive resident . 5. Staff will monitor for safe environment and to ensure no unusual episodes occur. Record review of facility incident report for Resident #6 dated 1/5/2025 at 8:30am indicated: Resident was in dining room near the smoking door with another resident when his w/c bumped into the other resident's chair. The other resident grabbed his and told him if he did it again, he would knock the shit out of him. Residents were separated and no further physical contact was made. Resident was assessed for injuries with none observed. Resident showed no signs of emotional trauma. Residents will not go on the same smoke breaks together. During an interview on 4/15/2025 at 11:25 AM revealed Resident #6 could not answer questions due to diagnosis of aphasia (language disorder that results from damage to the brain's language centers). During an interview on 4/15/2025 at 11:31am CNA D said Resident #3 moved back to the 500 hall yesterday 4/14/2025. She said she did not know what prompted the move back to the 500 hall. She said Resident #3 was smart mouthed and disrespectful to staff and residents. She said a staff member would be talking to another resident and Resident #3 will chime in with his negative input. She said she had seen the arguing with Resident #3 but had never seen him get physical with anyone. During an interview on 4/15/2025 at 12:52pm the ADON said he was an instigator and liked to create tiffs until other residents go off on him. She she had been employed at the facility since December 2024, Resident #3 had been sent to a behavioral hospital and had 2 room changes, and medication changes. She said the SW had been sending out referrals to discharge Resident #3, but no one would accept him. During an interview on 4/15/2025 at 1:13pm the DON said Resident #3 liked to stir the pot and instigate arguments with residents and staff. She said Resident #3 had been in a group home and multiple nursing homes prior to being at the facility. She said Resident #3 had issues when he was living at home with his mother and thought that APS had been involved because Resident #3 had acted out and called the police many times while he was there. She said Resident #3 was sent to Brentwood after he kicked Resident #6 at breakfast. During an interview on 4/16/2025 at 10:01am the SW said on 3/25/25 Resident #3 kicked Resident #6 during breakfast because he was making some noise and Resident #3 did not like it. She said he came to her office that morning and said he had kicked Resident #6 but did not know why he did it. She said on 11/30/2024 Resident #3 and Resident #4 were outside in the smoking area and were going back and forth arguing and both residents ended up on the ground. She said she couldn't remember if either one actually hit the other one. She said she couldn't remember any other physical altercations that she was aware of. She said Resident #3 was referred to counseling services on 11/5/24 but refused. She said on 2/19/25 the order and consent were received for counseling services, and he was evaluated by the counselor on 2/26/25. She said he had a verbal altercation a few days earlier and if another incident happened then they needed to seek further help for him. She said the Resident #3 received counseling services on Wednesday and the Psych MD and sees him monthly. She said she sent out 6 referrals to seek alternate placement for Resident #3 between 4/1/2025 and 4/15/2025 and all had been denied. During an interview on 4/16/2025 at 11:50am the Administrator said had a history of behaviors. She said she knew that the Resident #3 had behaviors before Resident #3 admitted to the facility, but she accepted him anyway because she felt like they could help Resident #3. She said Resident #3 liked to instigate and stir the pot with other residents and staff. She said Resident #3 often inserted himself into conversations with staff and residents that were not about him. She said Resident #3 knew what he was doing and would often apologize after an altercation with staff or other residents. She said her expectation was to do their best to prevent abuse and if something did happen they reported and took action. During an interview on 4/16/2025 at 1:21pm Resident #3 said when he was 28, he was in the hospital for 2 months and that's when he was diagnosed with the Wilson's disease. He said he is a sweet guy but when you him make him mad, he turns into the devil. He said he did not receive counseling services at the facility. He said he had only talked to a counselor 1 time since he had been at the facility. He said when he has the incidents with other residents, he will go an apologize after the incident was over. He said he did not have control over his actions when he gets mad, and he gets anxious. He said he told Resident #4 to tie his shoe and Resident #4 told him to shut up and for him to tie it and said he got up and started walking over to him and they just began fighting and fell to the ground in the smoking area. He said he kicked Resident #6 because he was jealous the staff were feeding Resident #6 and not him. He said he went to the behavior hospital after he kicked Resident #6. He said he got kicked out of another nursing facility for trying to bite the medication aide's finger. During an interview on 4/17/2025 at 1:25pm Resident #4 said he did not like Resident #3 and said on the day in question he was in the smoking area. He said Resident #3 told him his shoe was untied and he told Resident #3 it was none of his business. He said Resident #3 would not leave him alone and he got mad and him and Resident #3 mutually began fighting and fell on the ground. He said after the incident he did not like Resident #3 but he just tried to stay away from him and stay out of trouble. Record review of the facility's policy titled Abuse, dated 2/1/2017, reflected: . All events that involve an allegation of abuse or involve a suspicious serious bodily injury of unknown origin must be reported immediately or not later than 2 hours of alleged violation

Based on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care for 1 of 3 residents reviewed for baseline care plans. (Resident #1) The facility failed to develop a baseline care plan that addressed Resident #1's use of a fall mat at bedside and bed in the lowest position. This failure could place residents at risk of not receiving care and services to meet their needs. Findings Record review of the face sheet dated 07/05/2024 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including acute osteomyelitis (bone infection) of the right ankle and foot, muscle wasting, cognitive communication deficit, lack of coordination, hypertension (high blood pressure), pressure ulcers of the sacral area (a wound near the lower back and spine). Record review of the Admission MDS assessment dated [DATE] indicated Resident #1 was sometimes understood by others and sometimes understood others. The MDS indicated Resident #1 had a BIMS of 04 and was severely cognitively impaired. The MDS indicated Resident #1 was dependent with toileting, lower body dressing, and putting on and taking off footwear, required maximum assistance with bathing, and moderate assistance with upper body dressing. In section GG0120 Mobility devices the MDS indicated in the last 7 days Resident #1 used a walker and a wheelchair. Record review of the Order Summary Report dated 07/06/2024 indicated Resident #1 had an active order with a start date of 06/25/2024 for fall mat at bedside and bed to be in lowest position. Record review of the baseline care plan signed 06/25/2024 revealed it did not address the use of a fall mat at bedside and bed in the lowest position. Record review of an undated comprehensive care plan indicated Resident #1 was at increased risk for falls with the following interventions: Anticipate needs, provide prompt assistance. Assure lighting is adequate and areas are free of clutter. Encourage resident to ask for assistance of staff. Encourage socialization and activity attendance as tolerated. Ensure call light is in reach and answer promptly. The comprehensive care plan did not address the floor mat at bedside or the bed in lowest position. During an interview on 07/06/2024 at 04:15 PM, LVN A said she had worked at the facility as the charge nurse for approximately 2 years. LVN A stated the charge nurse completed admissions when the ADON or DON were not in the building. LVN A stated all new admission orders were placed in the system for the MARs and TARs and all that information combined and created the baseline care plan. LVN A stated Resident #1 required a fall mat at her bedside and the bed in the lowest position to prevent injury because she was at high risk for falls. LVN A stated that the care plan not addressing Resident #1's use of a floor mat at bedside would result in a gap in the care provided to Resident #1. During an interview on 07/06/2024 at 4:33 PM, the ADON said she and the DON were responsible for completing the baseline care plans. The ADON said she and the DON completed new admissions in the system including verifying and entering orders for the MAR and TAR daily and checked each other's work as the check and balance system to ensure an appropriate baseline plan of care was developed for the residents. The ADON said Resident #1 required a fall mat at her bedside and the bed in the lowest position to prevent injury because she was at high risk for falls. The ADON said Resident #1's order for the floor mat at bedside and bed in lowest position should have been included in the baseline care plan. The ADON said Resident #1's baseline care plan did not address the use of a fall mat at bedside because when Resident #1 admitted to the facility there had been a lot of admissions, and the DON was hospitalized . The ADON said the baseline care plans were important so staff would know what the residents' needs were and how to take care of them. During an interview on 07/06/2024 at 5:53 PM, the Administrator said the ADON and DON completed the baseline care plans. The Administrator said the ADON and DON switched out their work and verified each other's work was done appropriately by using a checkoff audit tool. The Administrator said the baseline care plans should be completed within the 48 hours after a resident was admitted to the facility. The Administrator said the baseline care plan ensured the best care was provided and prevented harm to the residents. Record review of a revised Baseline Care Plan policy dated 11/01/2019 indicated, a baseline care plan is required to be completed within 48 hours of admission. The baseline care plan must include: Initial goals based on admission orders , Physician Orders, Dietary Orders, Therapy Services, Social Services, PASARR ( if applicable) .The facility will provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: the initial goals of the resident, a summary of the resident's medications and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility, information to properly care for the resident upon admission, address specific health and safety concerns. The baseline care plan will be amended with any changes in care needs and those changes will be communicated to the resident and or resident's representative .

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen observed for kitchen sanitation. The kitchen floor, walls, and handles of the refrigerator had buildup of a sticky substance on [DATE]. There was a fan in use in the kitchen with dark thick substance on the fan blades and fan cover on [DATE]. The drink dispenser located in the kitchen had undated boxes of concentrate liquid and the orange liquid concentrate was on the floor and connected to the machine on [DATE]. The coffee dispenser had undated boxes of coffee concentrate connected to the machine and the machine had dried dark brown substance on the inside on [DATE]. The kitchen refrigerator stored unlabeled and expired objects on [DATE]. These deficient practices could place residents who ate food from the kitchen at risk for foodborne illness. Findings include: During an observation on [DATE] at 9:03 am the kitchen had buildup on the floors, walls, and handles of refrigerator of a dark sticky substance. There was a fan present in the prep area with dark thick buildup on blades and outside cover. The drink dispenser in the kitchen had 3 concentrated juices attached. The 3 containers were undated and the bag with an orange liquid concentrate was laying on the floor. The coffee dispenser in the dining room had 2 boxes of coffee concentrate and neither were dated and inside of the machine had a dark brown dried liquid substance on the inside. The refrigerator had 2 containers of cottage cheese container with best by date of [DATE], cranberry sauce in a reusable container dated to use by [DATE], an unlabeled meat link in a plastic bag, a bottle of red sauce dated as opened [DATE] and the directions read to use within 5 days of opening, an unlabeled yellow thick substance in a reusable container, and an unlabeled green pea substance in a reusable container. During an observation on [DATE] at 9:20 am of a coffee dispenser located in the dining room had a cleaning schedule located on the inside of the door that indicated a daily rinsing schedule and a weekly sanitizing schedule per manufacturer recommendations. During an interview on [DATE] at 9:26 am Cook F said that everyone was responsible for checking the refrigerator daily for unlabeled and expired items. She said that items should be labeled and dated and disposed of within 3 days or per the label or directions. She said she was not sure on the drink dispensers and if the boxes needed to be dated or not and was not aware of a cleaning schedule for the dispensers or the kitchen. She said she cleaned as she cooked. She said she had been trained on properly storing items and did the best she could, but other workers had to do their part when they were working. She said that an unsanitary kitchen and improper storage of foods could cause illness. During an interview on [DATE] at 9:40 am the DM said she was responsible for all duties in the kitchen and dining room and the kitchen staff should be cleaning daily, labeling, and storing food appropriately and all items should be dated. She said the staff had been trained on maintaining the kitchen in a sanitary condition. She said there was a cleaning schedule and the staff had been signing off that cleaning had been done. She said the drink dispensers were wiped down but the company that provided them were to deep clean them. She said she was not aware of the manufacturer weekly cleaning schedule listed inside the drink dispensers but would check into it. She said that by not maintaining kitchen sanitation it could lead to contamination and illness. During an interview on [DATE] at 4:00 pm the administrator said the dietary manager was responsible for oversight of the kitchen and she expected the kitchen to be cleaned and items stored in a sanitary manner. She said the staff had been trained on proper cleaning of the kitchen and how to label and store foods but would oversee more training was done. She said that an unsanitary kitchen could lead to illness and expected the kitchen to be maintained in a sanitary condition. Record review of a monthly kitchen cleaning schedule log indicated full cleaning performed in [DATE], February 2024, [DATE], and [DATE]. Record review of an in-service training dated [DATE] titled Dating and Labeling and cleaning indicated staff had been trained. Record review of an in-service training dated [DATE] titled deep cleaning kitchen and dating and labeling indicated staff had been trained. Record review of a facility policy titled Food Storage dated [DATE] indicated' .4. foods are stored at least 6 inches off the floor, 6. food removed from its original packaging will be labeled .

Based on observations, interviews, and record reviews, the facility failed to ensure correct installation, use, and maintenance of bed rails for two of twenty-one residents (Resident #1 and Resident #2) reviewed for bed rails. The facility failed to follow the manufacturers' recommendations and specifications for installing bed rails and developing care plan interventions for risk of entrapment. The facility assist bars installed on Resident #1 and Resident #2 ' s bed were not intended for use and care plans did not include risk for entrapment per manufacturer ' s specifications. Resident #1 expired at the facility after CNA A found him in his room with his neck between the assist bar and bed face down with his legs on the floor mat. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 2:12 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for entrapment with serious injury or death. Findings included: Resident #1 Review of a face sheet for Resident #1. Dated [DATE], revealed he was a [AGE] year old male admitted to the facility on [DATE] and had diagnoses including moderate dementia with mood disturbance, muscle wasting and atrophy to right and left shoulders, erosive osteoarthritis to left knee, and transient alteration of awareness. Review of Physician Orders, dated [DATE], revealed Resident #1 may have assist bars x 2 on bed to facilitate with turning and repositioning every day and night shift for bed mobility. Review of Resident #1 ' s Bed Rail Mobility Device Assessment, dated [DATE], revealed no concerns for risks of entrapment and assist bars were installed for bed mobility post falls following prior interventions of a floor mat and bed in low position. Review of Resident #1 ' s MDS, dated [DATE], revealed he had a Brief Interview for Mental Status score of 04, indicating severe cognitive impairment. Resident # ' 1 ' s functional status revealed he was non-ambulatory and required a two person assist for bed mobility. Review of Resident #1 ' s care plan, revised [DATE], revealed the resident had a history of falls and sliding off the bed with a recent fall on [DATE] where he was found on the floor mat with no injuries. The care plan revealed Resident #1 had a focus of being unable to bear weight or walk and limitations to legs and shoulders with interventions to include bilateral transfer bars. The care plan did not address the residents risk of entrapment. Bed Mobility Device Assessment Review of incident report log from [DATE] to [DATE] revealed Resident #1 had a fall on [DATE] and incident category listed as other [DATE]. Review of Provider Timeline Report, dated [DATE], revealed the following: *3:00 a.m., revealed CNA A last saw Resident #1 prior to incident during incontinent care check. *4:10 a.m., revealed CNA A found resident unresponsive with his head and neck between the assist bar and mattress. LVN A assessed, 911 was notified, AED device was placed by staff and CPR was initiated. EMS assisted with CPR. *4:38 a.m., EMS pronounced Resident #1 ' s death. *4:56 a.m., the administrator was notified of death. *5:17 a.m., revealed Regional Director of Operations was notified. *6:23 a.m., revealed police were notified. Three officers arrived, assessed incident, obtained witness statements, and notified the Justice of the Peace that ordered an autopsy. During an interview on [DATE] at 11:35 a.m., the Administrator said the Director of Plant Operations was responsible for bed and assist bar installation and maintenance. The Administrator said CNA A last saw Resident #1 during incontinent care rounds at 3:00 a.m. on [DATE] and he was doing fine and upon rounding at 4:10 a.m. CNA A noticed his legs were hanging off the bed and found him on the floor mat face down with his head and neck between the assist bar and bed. LVN A and the ADON assessed Resident #1 and there were no apparent injury or bruising at the time of the incident. AED device was obtained, and resident was a full code. CPR was initiated and EMS arrived and hooked him up to EKG, there were no readings, resident was determined deceased , and CPR was halted. The Administrator said Resident #1 ' s roommate was asleep and not aware of what had happened until the police came. The Administrator said Resident #1 ' s family member was notified by the ADON, and she called law enforcement and an autopsy was ordered. During an interview on [DATE] at 3:39 p.m., CNA A said she went in to check on Resident #1 at 3:00 a.m. on [DATE] and he was good, awake, and not trying to get off the bed. CNA A said when she went by his room at 4:10 a.m., Resident #1 was hanging off the bed with legs crossed on the floor, right arm was on the floor, and his neck was in between bed and rail. CNA A said she did not notice any injuries or bruising. CNA A said Resident #1 never used the assist bars on his bed and did not know why they were in place because he could not grip the bar to hold. CNA A said his bed did not appear to have any concerns with integrity of equipment. CNA A said it was important for assist bars to be installed per manufacturer ' s specifications to prevent all residents from getting hurt and pose a risk of entrapment to all resident using assist bars. CNA A said the Director of Plant Operations was responsible for installing and maintaining assist bars on beds and the facility has not provided her any training on bed safety or assist bars. During an interview on [DATE] at 2:49 p.m., LVN A said she last saw resident #1 during medication pass on [DATE] at 9:00 p.m. and said he was at baseline. LVN A said maintenance, the Director of Plant Operations, would be responsible for installing assist bars on the beds. LVN A said when someone falls, she typically does interventions such as placing a fall mat or providing education. She stated she did not know why the assist bar were installed on the residents bed and she was aware they could pose a risk of entrapment. LVN A said it was important for assist bars to be properly installed to prevent injury or death for all residents. During an interview on [DATE] at 12:28 p.m., the Administrator said following the incident with Resident #1, staff were in-serviced on bed safety and audit checks were completed on all resident beds with assist bars thoroughly checked and there were no concerns with integrity of assist bar equipment. During an interview on [DATE] at 2:15 p.m., LVN B said she was informed Resident #1 had gotten out of bed and got hung in the rail. LVN B said Resident #1 was a repeat faller, could not walk, had little movement, and could get his legs off the bed somehow with fall risk interventions of fall mat at bedside and keeping his bed low to the floor. LVN B said he has rolled of the bed before and have caught him with his legs off the bed and had to reposition him. LVN B said she did not know why they put the assist bar on his bed . She stated she had no concerns related to the beds ,assist bars or the use of the rail bars. She stated if she did, she would report to maintenance, the Director of Plant Operations. LVN B said following Resident #1 ' s incident, in-services were provided on bed safety. LVN B said hazards with using air mattresses and assist bars on beds could pose a risk of entrapment. During an interview and observation on [DATE] at 4:45 p.m., the Director of Plant Operations said the bed located in Resident #1 ' s room was the original bed and equipment for resident. The Director of Plant Operations said the bed manufacturer was [company 2], model P503, and the assist bar was manufactured by [company 1]. The Director of Plant operations said there was no gap allowed between the assist bar and bed for this type of assist bar. The Director of Plant Operations said he completed bed safety checks for all beds following Resident #1 ' s incident. The Director of Plant Operations said he was not aware that the assist bar was intended for use on[company 1].beds only per manufacturer ' s specification and that he installed the assist bars if the holes in resident bed frames lined up with the holes in assist bar. The Director of Plant Operations said it was important for assist rails to be installed properly to prevent the risk of injury or death and that improperly installed assist bars could pose a risk of entrapment. The Director of Plant Operations said he completed bed rail safety checks monthly and did not know if there were any [company 1]manufactured beds in the facility and that he did not keep an inventory of beds available. The Director of Plant Operations said the different white colored assist bars used in the facility were universal and that he did not have the manual for the universal assist bars. Review of [company 1] assist bar manual undated revealed the following: Warning: Possible Injury Or Death. This product is intended for use with [company 1] bed models ECS Series beds, B784, B694, B684, B624, B675, B530, B330, and B,d+[DATE]. Use of this product on any bed it was not designed for could result in an unproven or unsafe configuration, potentially resulting in serious injury or death . and It is also extremely important to review the resident/patient ' s physical and mental condition and initiate an appropriate individual care plan to address entrapment risk. Resident #2 Review of face sheet for Resident #2, dated [DATE], revealed she was a [AGE] year-old female admitted on [DATE] and had diagnoses including muscle wasting and atrophy to right and left shoulders, acquired absence of left leg above knee, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, age related osteoporosis, and encephalopathy. Review of Resident #2 ' s MDS, dated [DATE], revealed she a Brief Interview for Mental Status Score of 04, indicating severe impairment. Resident #2 ' s functional status revealed she was non-ambulatory and required a two person assist with bed mobility. Review of Resident #2 ' s care plan, revised [DATE], revealed she required extensive assist of two staff with bed mobility with intervention of bilateral transfer bars to assist with positioning and care. The care plan did not address the residents risk of entrapment. Review of Bed Mobility Device Assessment for Resident #2, dated [DATE], revealed no concerns for risks of entrapment and assist bars were installed for bed mobility. During an observation on [DATE] at 1:25 p.m., Resident #2 had a white universal assist bar installed to [company 2] manufactured bed, model P503. During an interview on [DATE] at 2:22 p.m., the Director of Plant Operations said he did not have a manual for the universal assist bars and provided a manufacture and model number of [company 3] 54588. Review of [company 3] 54588 assist bar manual from supplier online website, undated, revealed the following: Warning: Risk of serious injury or death. This product is intended only for use with [company 3] 1500, 3000, 3250, and 3500 beds. Do not use this device with any other model or brand of bed. Use of this product on any bed it was not designed for could result in an unproven or unsafe configuration, potentially resulting in serious injury or death. During an interview on [DATE] at 3:30 p.m., the Executive Director of Operations, Regional Nurse, and Clinical Reimbursement Coordinator said they will address Resident #2 ' s [company 3] assist bar installed on [company 2] manufactured bed not intended for use as soon as possible following HHSC Investigator intervention to ensure safety. During an interview on [DATE] at 3:50 p.m., the Executive Director of Plant Operations said [company 2] assist bar was available for Resident #2 ' s bed, however, the assist bar was removed following an assessment and determination that resident was not using assist bars as intended for repositioning and were removed with approval from the representative. During an interview and record review on [DATE] at 3:53 p.m., the Clinical Reimbursement Coordinator revealed care plan verbiage to be added to residents with assist bars that included risk for entrapment. Review of facility in-services, dated [DATE], revealed bed safety education was provided to nursing staff. Review of facility policy, titled Bed Safety, effective ,d+[DATE], revealed the following: Policy Focused Communities will strive to provide a safe sleeping environment for the resident. PROCEDURE 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. 2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. An inspection should be done by the Director of Plant Operations at installation/before use and quarterly thereafter of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. Review that gaps within the bed system are within the dimensions established by the FDA (Note: The review shall consider situations that could be caused by the resident's weight, movement, or bed position. c. Ensure that when bed system components are worn and need to be replaced, they are replaced with compatible components that meet manufacturer specifications; d. Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard and footboard, etc.); and . 10. When using side rails for any reason, the staff shall take measures to reduce related risks. The Executive Director of Operations was notified of the Immediate Jeopardy on [DATE] at 2:12 p.m. and was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal was accepted on [DATE] at 12:54 p.m. and reflected the following: Part 1: Identification of Recipients: 1 The resident directly affected by the deficient practice is no longer in the community. Part 2: Actions to Prevent Occurrence or Recurrence: 1. Universal Assist bar was removed from additional resident with air mattress on [DATE]. 2. All facility policies and procedures regarding assist rails were reviewed during Ad Hoc QAPI with Medical Director on [DATE]. 3. The DON or designee will educate all staff, prior to their next scheduled shift, on the proper use of assist rails per facility policy, the process of determining proper use of side rails depending on resident ' s mental and physical status, and the increased risk of injury and death when assist rails are used improperly. Education will include bed mobility device inspection, FDA recommended space and instruction to report gaps greater than recommendation to DON/Administrator/Maintenance Director. Education will begin [DATE] and completed [DATE] before the start of their next scheduled shift. a. Newly hired personnel will be educated on the proper use of assist rails per facility policy, the process of determining proper use of side rails depending on resident ' s mental and physical status, and the increased risk of injury and death when assist rails are used improperly. 4. Maintenance personnel provided 1:1 inservice on installation of all assist bars per manufacture guideline on [DATE] by the Regional Nurse. Manufacturer guidelines will be available to any staff installing assist bars. The guidelines will be located in the Administrator and Maintenance Director ' s office and at nurse ' s station. 5. The IDT reviewed all residents with assist bars to determine the appropriateness of continued assist bar placement and risk of entrapment on [DATE]. All residents utilizing assist bars will have a Bed Mobility Device assessment completed on [DATE] by 1p.m. 6. The IDT reviewed the care plans of residents with bed rails to ensure they include risk associated with use of assist bars completed on [DATE]. On [DATE] at 5:30 p.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Removal of assist bars not intended for use from beds and replacement with approved assist bar per manufacturer ' s specification, Review of in-services revealed staff training was completed on bed mobility zone gap recommendations, care plans updates included entrapment risk for residents with assist bars, interviews with staff demonstrating knowledge and location of bed mobility inspection sheet at nursing station, and bed inventory list with approved bed manufacture for assist bars used. During an interview and record review on [DATE] at 4:03 p.m., the Executive Director of Operations said the interdisciplinary team consisted of the DON or Interim Administrator, MDS Coordinator, Activity Director, Social Worker, Rehab Director, ADON, Maintenance Director, Medical Director, and included herself. The Executive Director of Plant Operations said staff received in-services per plan of removal, care plans were updated to include risk of entrapment, and assist bars not intended for use were removed from service. The Executive Director of Operations said only[company 2] manufactured beds with[company 2] assist bars were now utilized for resident beds at the facility to ensure manufacturer specifications were being met and was in the process of obtaining and replacing approved beds. Review of resident assist bar audit tool, care plan tasks, and physician order listing report, dated [DATE], revealed rental beds were listed, [company 2] manufactured beds were rented, care plans were updated, and physician orders revealed assist bars were in place for repositioning and turning of residents. The Executive Director of Operations said it was important for staff to follow the assist bar manufacturer guidelines to ensure they are properly installed and used accordingly to reduce risks for any hazards including injury or entrapment and that not following manufacturer ' s guidelines could pose a risk to the residents that are using assist rails. The Executive Director of Operation said the facility has reassessed residents with assist bars installed and determined that some assist bars were no longer needed based on their ability to use the bar as intended for bed mobility. The Executive Director said family was contacted to approve removal of bars prior to removal and education was provided to residents and representatives on risks of using them. The Executive Director of Operations said the facility provided a legend with 4-,d+[DATE] inch requirement on bed mobility inspection sheet from FDA (Food and Drug Administration) recommendation for Zone 3 between assist bar and mattress and that the sheet will be located at the nurse station in the bed assist form manual and provided to every employee. The Executive Director of Operations said completion of[company 2] manufactured assist bars installation on Drive manufactured beds will be done by the end of the day. Review of in-service, dated [DATE], revealed training was provided to nursing staff on proper use of assist rails to include assessment for assist bars on care plan prior to usage. In-service revealed bed mobility inspection sheet that included gap recommendation of less than 4-,d+[DATE] for Zone 3 located between bed rail and mattress. During an interview on [DATE] at 4:15 p.m., CNA B said she had been employed at the facility for 3 years and that training was provided on bed safety via in-services. CNA B said the maintenance man, Director of Plant Operations, would be responsible for installing bed rails or assist bars. CNA B said if assist bars were not installed per manufacturer guidelines it could pose a risk of entrapment and affect any resident with an assist bar. During an interview on [DATE] at 4:23 p.m., CNA C said to ensure beds are safe she made sure the bed was low, and made sure bed rails are secure, and look for space in between assist bar and bed so residents cannot get stuck in between them and uses length of badge as a reference for gap recommendation. CNA C said it was important for assist bars to be installed properly to prevent entrapment and could pose a risk of death if installed on beds not intended for use. During an interview on [DATE] at 4:41 p.m., LVN C said she had been employed by facility for a year and a half. LVN C said residents were reassessed for assist bar use and knew that one resident had assist bars removed due to risk. LVN C said the facility provided training on bed safety today and that maintenance would be responsible for installing assist bars on the beds. LVN C said it would be a risk if a bed was not intended for use with an assist bar because it may malfunction and cause a risk for entrapment. During an interview on [DATE] at 4:48 p.m., LVN D said she had been employed for 3 and a half years. LVN D said the facility provided in-services and the manual at the nurse station goes over bed rails. LVN D said it was important to install the assist bar as intended to prevent incidents or accidents and said residents could fall and get injured and posed a risk for entrapment. LVN D said if there was gap in Zone 3 that was bigger than 4-,d+[DATE] she would notify maintenance and Administrator to make sure they addressed concerns. During an interview and record review on [DATE] at 5:10 p.m., the Clinical Reimbursement Coordinator said blanks on the assist bar assessment audit tool were residents waiting on new beds. During an interview on [DATE] at 5:20 p.m., the Director of Plant Operations said assist bars had been replaced and were now only using [company 2] brand assist bars., model P503 and P903. The Director of plant Operation said he reviewed with the Regional Nurse on how to properly install the Drive assist bars and ensure safety by making sure we are following manufacturer guidelines. The Director of Plant Operations said he was checking beds weekly for proper install and that all staff were provided and referring to gap recommendation of less than 4-,d+[DATE] on the bed mobility device inspection sheet for Zone 3 between bed rail and mattress. The Director of Plant Operations said staff are being asked questions and that a small test will be conducted on bed safety in a couple of days to demonstrate retention of knowledge. On [DATE] at 5:30 p.m., the Executive Director of Operations was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure cardiopulmonary resuscitation (CPR) was provided in accordance with professional standards of practice for 1 of 1 resident reviewed for CPR. (Resident # 49) The facility did not immediately provide CPR and call 911 for Resident #1 who was a full code (wanted all possible life saving measures in the event her heart or breathing stopped) when the resident was found without a pulse. LVN H assessed Resident #1 and determined the resident did not have a pulse or respirations. LVN H waited until RN J arrived back to facility before CPR was initiated. The resident was pronounced dead on arrival to the hospital. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a isolated incident of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents who had a full code status at risk of death. Findings included: Consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #49 was [AGE] years old, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS dated [DATE] indicated Resident #49 understood others and was understood. The MDS indicated Resident #49's cognition was intact. The MDS indicated Resident #49 required extensive assistance with ADLs. The MDS indicated Resident #49 had not refused care. The care plan dated [DATE] did not address Resident #49's code status. The MDS dated [DATE] indicated Resident #49 had an unplanned discharge on [DATE]. A nursing progress note dated [DATE] at 11:15 p.m. by RN J indicated received a call to return to the facility to pronounce time of death at approximately 10:30 p.m. Upon arrival to the facility, I discovered the client was a full code. Compressions were started and client was transported to the emergency via 911. A nursing progress note dated [DATE] at 11:51 p.m. by LVN H indicated Entered 300 hall at approximately 7:30 p.m. - 8:00 p.m. Resident noted lying in bed, drowsy. Offered resident her medication, resident shook head no. Attempted to check vital signs, resident stated she was tired and would not allow nurse to check blood pressure or pulse. Respirations noted at approximately 16 watching by chest movements. At 10:00 p.m. CNA entered residents room at approximately 10:30 p.m. CNA attempted to arouse resident and could not. CNA came to nurse and stated resident was unresponsive. Entered resident's room and attempted to arouse. Unable to arouse. RN on duty called code due to resident's full code status. CPR began and 911 was called. EMS arrived at facility at approximately 10:50 p.m. EMS cardiac monitor showed weak and thready (scarcely perceptible) pulse. Resident was taken to Center ER and passed away. Hospital records dated [DATE] at 11:23 p.m. indicated Resident #49 was seen on [DATE]. The record indicated Resident #49 presented in cardiac arrest. The initial cardiac rhythm was asystole (the most serious form of cardiac arrest. The state of total cessation of electrical activity from the heart). The records indicated pre-arrival treatment was discussed with the EMS (emergency medical services). The additional history reported was Resident #49 was found unresponsive at 8:00 p.m. by the nurse at the facility. CPR (cardiopulmonary resuscitation) was initiated. When EMS arrived, the monitor showed asystole. No pulse. She was intubated (procedure that is used when you can not breathe on your own. A tube is inserted down your throat into your windpipe), given [MEDICATION(S)] (medication which is involved in regulating respirations) CPR continued, and she was transported to the hospital. The hospital records indicated the Resident #49 was unresponsive with no pulse. Her skin was cool. Her pupils were midline and fixed. There were no heart sounds. On arrival, Resident #49 was placed on the cardiac monitor and the rhythm was asystole. She had no pulse. Resuscitation was terminated. She was declared dead at 11:20 p.m. During an interview on [DATE] at 9:02 a.m., the administrator said she remembered the incident with Resident #49. She said the facility was in a COVID crisis at the time and had rapid response employees provided by the state working. The administrator said LVN H had called her on [DATE]. The administrator said she could not remember the time. She said LVN H told her Resident #49 had passed away. The administrator said she asked LVN H who had pronounced time of death and LVN H said she had. The administrator said she told LVN H a RN had to pronounce time of death so she needed to call RN J and see if he would come back to the facility. The administrator said she was not aware RN J returned to the facility and initiated CPR. The administrator said she did not hear anything else about Resident #49's death so she assumed everything had been fine. The administrator said she found out this morning ([DATE]) RN J had initiated CPR and Resident #49 was transferred to the hospital and expired. During an interview on [DATE] at 9:46 a.m., RN J said he worked at the facility as a part of relief assistance. He said he received a phone call from the facility on [DATE] at approximately 10:30 p.m. RN J said he could not remember who made the call. He said he was asked to return to the facility to pronounce time of death on a resident. RN J said he arrived at the facility approximately 10 minutes later. RN J said he was only allowed to pronounce time of death on DNR's (do not resuscitate) so upon arrival to the facility he asked LVN H what Resident #49's code status was. RN J said he was told Resident #49 was a DNR. RN J said he asked to see the signed paperwork to verify her code status. RN J said they discovered Resident #49 was a full code. RN J said he immediately went to Resident #49's room to assess her. RN J said he felt a very faint pulse. RN J said there was no rise or fall to her chest. RN J said he immediately initiated CPR and 911 was called. RN J said there had been no interventions started prior to his arrival. RN J said the AED (automated external defibrillator) was not used. He said he thought it was brought to the room, but it was not charged. During an interview on [DATE] at 2:06 p.m., LVN H said she worked on [DATE] when Resident # 49 expired. LVN H said she had checked on Resident #49 at approximately 8:00 p.m. She said Resident #49 did not feel good and did not want to take her medications. She said Resident #49 refused to let her take her vitals. LVN H said the CNA notified her at approximately 10:00 pm on [DATE] that Resident #49 had expired. LVN H said she looked in the computer and saw Resident #49 was a full code. LVN H said she went and assessed Resident #49. LVN H said She was pretty gone. She was not cold but you could tell she was gone. LVN H said she checked for a pulse and could not feel one. She said she listened for heart sounds and could not hear anything. LVN H said she went to the nurse's station and called her ADON to see what she needed to do. LVN H said she had never worked a code and was unsure. LVN H said the ADON did not answer so she called the administrator. LVN H said the administrator said she was not a nurse and did not know what to do. She said the administrator told her to call RN J. LVN H said she called the ADON again. She said the ADON told her she had not worked a code and was unsure what to do. LVN H said another agency nurse called RN J. LVN H said she returned to Resident #49's room and initiated CPR with CNA L and an agency CNA. LVN H said approximately 10 minutes had passed. She said they pushed the crash cart in the room and put the backboard behind Resident #49. She said she did 3 rounds of compressions before RN J arrived and relieved her. During an interview on [DATE] at 2:53 p.m., CNA L said she worked [DATE] when Resident #49 had expired. She said she went to Resident #49's room. She said she could not remember what time. She said the agency CNA was sure Resident #49 had passed. CNA L said LVN H could not find a pulse on Resident #49. CNA L said LVN H was not sure what to do so she went and made some phone calls. She said LVN H said they had to call RN J back to pronounce time of death. CNA L said RN J arrived and they discovered she was a full code and they were supposed to start life saving measures. CNA L said she went to Resident #49's room with RN J, LVN H, and an agency CNA. She said they started CPR. CNA L said they did not start CPR until RN J arrived. CNA L said no one knew what to do before RN J arrived. CNA L said RN J and LVN H took turns doing compressions and the agency CNA and herself did the breathing. CNA L said she could not remember if they had used the AED. During an interview on [DATE] at 7:47 p.m., LVN H said she had assessed Resident #49 at approximately 8:00 p.m., She had taken her blood pressure and pulse and they were normal. She said she thought she charted the vitals in the computer. LVN H said Resident #49 said she did not feel good and wanted to be left alone. She said she refused her medications. LVN H said the agency nurse told her Resident #49 had expired at approximately 10:00 p.m. LVN H said she looked at the computer and saw she was a full code. LVN H said she went to Resident #49's room to assess her. LVN H said Resident #49 was lying in bed the way she had left her at 8:00 p.m. She had her arms crossed and her head turned to the side. LVN H said she checked for a pulse and listened for heart sounds. She said she could not feel a pulse or hear anything. LVN H said she went back to the nurse's station and started making calls. She said she called the ADON twice and the administrator. She said she told someone to call RN J, but she could not remember who she told to make the call. She believed it was the other agency nurse. LVN H said RN J arrived and said they had to start CPR. She said they returned to Resident #49's room and they started CPR. LVN H said she went and got the AED but by the time they had it hooked up, EMS had shown up and taken over. LVN H said she had never worked a code and was not sure what she was supposed to do. LVN H said she was currently CPR certified. LVN H said she never should have left Resident #49 and she should have started the CPR immediately. The employee file for LVN H indicated she was hired on [DATE]. LVN H's CPR certification was current. A Cardiopulmonary Resuscitation policy revised [DATE] indicated .Sudden cardiac arrest is a loss of heart function due to abnormal heart rhythms. Cardiac arrest occurs soon after symptoms appear. It is the leading cause of death in adults .The chances of surviving cardiac arrest may be increased if CPR is initiated immediately upon collapse .early delivery of a shock with a defibrillator plus CPR within ,d+[DATE] minutes of collapse can further increase chances of survival .if an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR shall initiate CPR unless it is known that a DNR exists or there are obvious signs of irreversible death such as rigor mortis .if an individual is found unresponsive, briefly assess for abnormal breathing. If cardiac arrest is likely, begin CPR. Instruct a staff member to call 911. Instruct a staff member to retrieve the AED. Initiate the basic life support sequence of events .when the AED arrives assess for need and follow AED protocol .Continue with CPR until emergency medical personnel arrive . According to cpr.heart.org, accessed on [DATE] at 12:53 p.m., Immediate CPR can double or triple chances of survival after cardiac arrest. The facility administrator and DON were notified of the IJ on [DATE] at 12:50 p.m. They were given the IJ template and a plan of removal was requested. The facility's Plan of Removal was accepted on [DATE] at 4:30 p.m. and included: *Review all records to ensure that Code status is correct. Completed [DATE] by the DCO. *Review Code status to ensure that appropriate code is reflected in Care Plan and in Kardex. Completed [DATE] by the DCO *Ensure Documents are uploaded into the Electronic Medical Record. Completed [DATE] by The DCO/or designee *Licensed Nurses will be provided in-service education beginning on [DATE] by DCO or designee which includes: 1.Nightly monitoring of Crash Cart to include expiration dates. 2.Locating Resident Code status in Electronic Medical Records. 3.Location of AED, use, and nightly checks to include battery is charged. 4.Correct action to take if resident found unresponsive. *Staff who are unavailable prior to the designated completion date will receive education prior to providing any hands-on care. New hires will receive this education as part of the new hire education. *LVN H will receive 1:1 in-service education related to how to obtain code status for residents and when to initiate CPR by the DCO/or designee. *All Education/In-servicing will be done by [DATE]. Validation/Monitoring Tools -DCO or Designee will validate staff knowledge base through random questioning. -Social Service and or Nursing will review new admissions and/or Changes in Code status to ensure they are reflective of resident choice. -Code Status will be reviewed with each Care Plan conference. *QAPI-The Administrator/[NAME] will review the action plan developed related to Code Status, and documentation. The surveyors confirmed the POR had been implemented sufficiently on [DATE] at 9:30 a.m. to remove the IJ by: During interviews with 16 staff (9 LVNs, 1 RN, and 6 CNAs) they were able to appropriately define full code status and DNR status, identify the location of the AED and crash cart, provided the procedure to follow for a resident found unresponsive with no vital signs that was a full code. Chart reviews were completed and reflected residents code status. Resident care plans included their code status. The crash cart was observed to have supplies and staff signed daily that the crash cart was checked. The AED was working and monitoring forms for [DATE] indicated nightly checks were being performed.

Based on interview and record review, the facility failed to ensure pain management was provided consistently with professional standards of practice, the comprehensive person-centered care plan and in accordance with goals and preferences for 1 of 4 residents reviewed for pain. (Resident #1) The facility did not provide timely pain management for Resident #1. Resident # 1 complained of pain to his right foot and lower leg. The resident did not receive interventions to manage the pain for 20 hours and 10 minutes. The resident was transferred to the hospital where he was diagnosed with [REDACTED]. This failure could place residents who need pain management at risk for prolonged pain and neglect. Finding included: A face sheet dated 10/16/19 indicated Resident #1 was a [AGE] year old male, admitted [DATE], with [DIAGNOSES REDACTED]. A care plan dated 09/16/19 indicated Resident #1 had the potential for acute and chronic pain and was at risk for injury from decreased ADLs due to [MEDICAL CONDITIONS](stroke). The only listed goal was to maintain current ADL's and pain/discomfort will be relieved within one (1) hour after intervention. Interventions were as follows: Assess characteristics of pain: location, severity, on a dementia scale - PAINAD, type and frequency. *Discuss with resident factors that precipitate pain and what may reduce it. * Administer pain medications as ordered. *Discuss with resident the need to request pain medications before pain becomes severe. * Discuss with physician that for maximum pain relief pain medication are best given around the clock, with prns for breakthrough pain. *Monitor for potential side effects of pain medication. *[MEDICATION NAME] Tablet 600 mg - give one tablet by mouth two times a day for metabolic [MEDICAL CONDITION]. A care plan dated 09/16/19 indicated Resident #1 had a history of [REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 had clear speech, the ability to make himself understood and understood others with corrective lenses. Resident #1 was severely cognitively impaired with no rejection of care behaviors noted. He required extensive physical assistance of two people for bed mobility and extensive physical assistance of one person for transfers, dressing, toilet use and personal hygiene. A nursing note dated 10/14/19 at 5:20 p.m. indicated Resident #1 returned to the facility from a behavioral hospital with no distress noted. This note indicated Resident #1 was pleasant going back into the unit as others spoke, asking where he had been. During an interview on 10/22/19 at 8:40 a.m., the Administrator said she held the door for Resident #1 to enter the secured unit upon his initial return to the facility 10/14/19. She said the mental health van driver was pushing Resident #1 into the facility backward with no legs on the wheelchair. The administrator said Resident #1 did not complain of pain upon returning to the facility 10/14/19. The Admit/Readmit Screener dated 10/14/19 at 4:55 p.m. indicated Resident #1 had no swelling, discoloration or any skin issues. This document indicated 0 in the pain section indicating Resident #1 had no pain upon readmission. A nursing note dated 10/14/19 at 5:40 p.m. indicated Resident #1's right foot was slightly bent behind his leg to where it was in the middle of the wheelchair. We positioned it and (Resident #1) did complain of some foot pain on right side and lower leg. The documentation indicated the physician was not notified and Resident #1 was not medicated for pain. During an interview on 10/22/19 at 10:13 a.m., the DON said when Resident #1 arrived back from a mental health facility, he did not grimace or demonstrate any signs of pain. She said Resident #1 continued smiling and speaking to everyone as he was assisted into the building. The DON said after readmission, Resident #1 was found with his right foot bent underneath his wheelchair and refused to stand for an assessment. The DON said an unknown staff pulled Resident #1's right foot from under the wheelchair to stand him up and Resident #1 yelled, OOW!! My foot! The DON said the nurse assumed it was because of how Resident #1's foot was positioned so there was no pain medication administered and the physician was not informed of a complaint of pain. She said it was when Resident #1 was assisted to bed CNA A found Resident #1's foot externally rotated. A nursing note dated 10/14/19 at 9:00 p.m. indicated Resident #1 was in bed and was noted with his right foot inverted outward to right, this nurse tried to straighten foot and Resident #1 screamed when trying to straighten foot and Resident #1 screams when you touch his right foot. The nurse notified the physician and received new order for two view right foot x-ray and right hip x-ray. During an interview on 10/22/19 at 10:43 a.m., the DON said the handwritten statement by CNA A indicated Resident #1's right foot was turned outward at 6:45 p.m. and notified the nurse. The DON said Resident #1 was not given any pain medication at the facility before being transferred to the hospital with a fracture. A nursing note dated 10/14/19 at 9:03 p.m. indicated the mobile x-ray was notified of the order for Resident #1 to have x-ray of right foot and hip. A nursing note dated 10/14/19 at 9:37 p.m. indicated Resident was assessed for pain. At this time, Resident #1 complained of right foot pain. A nursing note dated 10/15/19 at 1:19 a.m. indicated the mobile unit arrived to x-ray Resident #1's right hip and foot. A nursing note dated 10/15/19 at 7:00 a.m. indicated Resident #1 was in bed, his right hip was swollen and he was complaining of pain. The CNA was instructed by the nurse to keep Resident #1 in bed until the x-ray report was received. A nursing note dated 10/15/19 at 8:33 a.m. indicated Resident #1 denied being in pain and did not need pain medications. A nursing note dated 10/15/19 at 1:00 p.m. indicated x-ray results of Resident #1's right hip, pelvis and foot were received. The physician was notified and a new order was received to send Resident #1 to the emergency room . A nursing note dated 10/15/19 at 1:30 p.m. indicated EMS arrived and Resident #1 was taken by stretcher. Resident #1 remained in an area hospital at the time of this investigation. A hospital document entitled Progress Note EMR Preliminary Report dated 10/16/19 indicated Resident #1's x-ray results dated 10/15/19 at 3:46 p.m. showed intertrochanteric [MEDICAL CONDITION] femur. A MAR indicated [REDACTED]. [MEDICATION NAME] 600 mg was ordered for metabolic [MEDICAL CONDITION]. A MAR indicated [REDACTED]. A nursing note dated 09/14/19 indicated Resident #1 asked for a pain pill but does not have PRN pain medications. During an interview on 10/22/19 at 12:37 p.m., CNA A said Resident #1 was conversational and showed no signs of pain upon return to the secured unit. She said she when Resident #1 was assisted to stand for the nursing assessment he yelled, OUCH!! CNA A said LVN B said Resident #1's foot was oddly positioned and in pain because he had been holding it under the chair too long. CNA A said Resident #1 was lifted from his wheelchair to bed and, after he was laid down his foot just flopped over and that's when I got the nurse and she came, looked at the positioning and said something was wrong so LVN B ordered x-rays. A facility policy on pain management requested from the DON was not provided during this investigation. During an interview on 10/22/19 at 1:19 p.m., the facility was asked for additional information regarding Resident #1's injury and pain at exit. No additional information was provided.

Based on observation, interview, and record review, the facility failed to ensure residents were protected from abuse for 2 of 7 residents reviewed for abuse and neglect.(Residents #s 20 and 41) The facility did not prevent resident to resident abuse when Resident #20, who had a history of [REDACTED].#41, was found with Resident #41 in his bed with her shirt up as he was taking his pants off next to her. Resident #20 started making sexually inappropriate comments towards Resident #41 on 8/8/18 and was ordered medication to decrease his libido; however, it was ineffective and he continued the behavior. Resident #20 made mulitple attempts to lure Resident #41 into his room and continued making lude sexual comments to the resident. No new interventions were attempted. An Immediate Jeopardy was identified on 8/22/18. The Immediate Jeopardy was removed on 8/23/18; however, the facility remained out of compliance at a pattern of potential for more than minimal harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 5 female residents who resided on the secure unit at risk for abuse. Findings included: 1. Physician orders [REDACTED].#41, admitted [DATE], was a [AGE] year old female with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #41 was rarely or never understood, had short and long term memory problems, and was assessed by staff to have moderately impaired skills for decision making. Resident #41 needed extensive assistance for transfers, dressing, eating, and toileting, and was totally dependent on staff for bathing. Resident #41 did not require the use of mobility devices. A care plan dated 6/27/18 indicated Resident #41's focus areas included impaired cognitive function, communication problem related to disorganized speech, and an inability to make needs known. The care plan indicated Resident #41 was rarely understood, and sometimes understood simple and direct communication. Resident #41 paced and resisted care. The care plan indicated Resident #41 wandered and was at risk of elopement related to dementia. Resident #41 resided on the secure unit, where she paced and wandered throughout the day and night. 2. Physician orders [REDACTED].#20, admitted [DATE], was an [AGE] year old male with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#20 was to receive [MEDICATION NAME] (causes decreased libido) 5 mg daily due to sexual behaviors. A care plan dated 7/10/18 indicated a focus area for Resident #20 included communication deficit related to poor hearing and disorganized thinking, impaired cognitive function, and he was an elopement risk. The care plan indicated Resident #20 had a history of [REDACTED]. It did not address any inappropriate sexual behaviors. A review of nursing notes for Resident #20 included: *8/1/18 1:30 p.m., by LVN R - Resident #20 returned to facility from a local behavioral hospital. *8/2/18 8:46 p.m., by LVN S - The resident wandered about on the secure unit with a walker, very talkative, and stated I need to have sex. Informed the resident that his wife was asleep, and resident stated, well maybe you can help me out. Nurse attempted to redirect the resident and change the subject, it worked briefly, [MEDICATION NAME] given as ordered. *8/8/18 8:27 a.m., by LVN A - Resident noted to have increased sexual activity towards another resident noted (resident not identified). Resident #20 saw the female resident down the hall walking by his room and cat called (make a [MEDICATION NAME], shout, or comment of a sexual nature to a woman passing by) the other resident. Physician notified, staff aware. *8/8/18 6:16 p.m. by LVN A - New order for [MEDICATION NAME] 5 mg one by mouth every day for noted sexual behavior. The most recent MDS dated [DATE] indicated Resident #20 had a severe cognitive impairment and required supervision only for most ADLs. The assessment indicated no behavioral symptoms were present. A TAR dated (MONTH) (YEAR) indicated Resident #20 received [MEDICATION NAME] 5 mg daily from 8/9/18 through 8/23/18. There was no indication if the medication was effective noted on the TAR. During an interview on 8/21/18 at 2:25 p.m., CNA E said Resident #41 wandered all the time. She said Resident #20 started saying inappropriate things to her such as come in here and let me show you what I have or that he wanted sex. CNA E said there was one time that she and CNA D were in another resident's room and when they came out, neither Resident #20 nor Resident #41 were visible and the door to Resident #20's room was shut. She said when she went in Resident #20's room, Resident #41 was lying in bed with her shirt pulled up midway and Resident #20 was taking his pants off next to Resident #41. CNA E said when she entered Resident #20's room he said, you caught me I guess you knew what I was about to do. CNA E could not recall the date and time of the event, nor which nurse she notified. During an interview on 8/21/18 at 2:17 p.m., CNA D said Resident #20 had been trying to get Resident #41 in his room with him. CNA D said she and the other CNAs tried to keep them separated. CNA D said Resident #41 would start to go into Resident #20's room, but they caught her before she could walk in the room. CNA D said she saw Resident #41 in Resident #20's room before, but I got her out. CNA D said she told all of the nurses who worked on the 2-10 shift about Resident #20's behavior. CNA D said Resident #20 asked her one night if she ever had a man jump on her before. During an interview on 8/21/18 at 2:08 p.m., CNA C said she heard about the incidents from CNA D and CNA E. She said the times Resident #20 would get Resident #41 into his room was when the CNAs were in another resident's room. CNA C said Resident #20 was sneaky and would do something in a split second. She said the reason he was on the secure unit was because he had a history of [REDACTED]. During an interview on 8/22/18 at 1:09 p.m., CNA C said she witnessed Resident #20 make sexually inappropriate statements to Resident #41. CNA C said one time Resident #20 was not aware that she was behind him when he was walking behind Resident #41 and whispered to the resident, I sure do like that pussy. CNA C said she witnessed Resident #20 try to lure Resident #41 into his room. CNA C said Resident #20 would stand in the doorway of his room and whisper to Resident #41 to try and make her come into his room. CNA C said she had seen Resident #20 do that 15-20 times. CNA C said she reported it to the nurse every day that it happened. She said she reported it to the nurse at least five times of Resident #20's sexual behavior towards Resident #41. CNA C said she reported it to LVN A and also to an unidentified LVN. During an interview on 8/21/18 at 1:25 p.m., LVN A said Resident #20 had dementia, and had been having sexual behaviors toward Resident #41. LVN A said Resident #20 would say explicit things to Resident #41, such as I want that pussy. LVN A said when Resident #20 was walking in the hall he would try to get Resident #41 to come into his room. LVN A said once she was told by CNA C that Resident #20 and Resident #41 had swapped shirts or something, and that the physician started Resident #20 on [MEDICATION NAME] to see if it would help with the behaviors. LVN A said this morning Resident #20 said, I want that pussy to Resident #41 as she walked by his room. During an interview on 8/21/18 at 12:36 p.m., CNA C said Resident #20 had sexual behaviors toward Resident #41. CNA C said Resident #20 tried to get Resident #41 into his room and had been successful twice. CNA C said she heard about it from other staff. CNA C said once when they found Resident #20, Resident #41 was lying in his bed, and another time he had taken off her shirt and put his sleep shirt onto her. CNA C said CNA E indicated she reported it to the nurse. During an interview on 8/21/18 at 4:30 p.m., CNA H said Resident #20 was known to try to get Resident #41 to come into his room. During an interview on 8/21/18 at 2:47 p.m., the DON said she first learned of Resident #20's sexually inappropriate behavior when she read the nursing note in his record dated 8/8/18. The DON said there were no incident reports regarding Resident #20's sexual behaviors, and that no one had reported it to her. The DON said Resident #20's physician prescribed [MEDICATION NAME] (used to treat benign enlargement of the prostate) to address the sexual behavior, but she was uncertain if it had been effective. The DON said no other interventions to address Resident #20's inappropriate sexual behaviors towards Resident #41 were implemented. The DON said she was not aware of any inappropriate physical contact by Resident #20 toward any resident. The DON said the progress note dated 8/8/18 referred to Resident #20 and Resident #41. The DON said she had no knowledge of the incident regarding the alleged incident described by CNA E. She said if it occurred, there should have been an incident report, and that it should have been reported to the state. During an interview on 8/22/18 at 1:50 p.m., the DON said CNA E could not recall the day or time the incident with Resident #41 being found in bed in Resident #20's room, but CNA E remembered working with CNA F during the 2-10 shift. The DON said CNA E and CNA F worked together most recently on 8/13/18. The DON said nurses who were working that day had no knowledge of the incident. The DON said there were no interventions regarding sexually inappropriate behavior on Resident #20's care plan. An abuse policy dated 7/10/18 indicated the purpose of the policy was to ensure that each resident had the right to be free from any type of abuse or neglect. The administrator was informed on 08/22/18 at 4:20 p.m. that there was an Immediate Jeopardy situation due to the above failures. The facility's plan of removal was accepted on 8/22/18 at 6:45 p.m. and included: *The physician was notified with orders received to refer Resident #20 to a behavior Hospital *Behavior hospital contacted. *Family members notified for both residents *CNA E was suspended 8/22/18 pending investigation regarding CNA not following facility policy on reporting abuse or neglect. *Staff educated on facility policy and procedures for prompt reporting of Abuse/Neglect, started 8-21-18 with no one working the floor until in-serviced . *Resident #20 was placed on one on one supervision until alternate placement found. One on One would be with a staff member within ten feet and eye sight, staying with the resident at all times. Facility to document monitoring on a fifteen minute paper monitoring sheet Resident #41 showing no signs or symptoms of emotional distress *All female residents on secured Hall were given head to toe assessments with no suspicious bruises noted. *Emergency Q.A. meeting held with Medical Director 8-22-18. Medical Director suggested looking into other Behavior Hospitals if the first one would not accept Resident #20. *Life satisfaction surveys to be done *Provide additional information through Relias Learning on Sexual Acting Out - Dementia. *Goal was to have Resident #20 discharged by end of business day 8-23-18, facility Social Worker was reaching out to other Behavior Hospitals looking for placement *Attached a one on one schedule for Resident #20 through Friday (8/24/18). On 08/23/18, the surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: -During observations, Resident #20 was placed on 1:1 observation by facility staff starting at 4:20 p.m. on 8/22/18 when the IJ was called. -Review of documentation indicated the 1:1 observation of Resident #20 had been continuous since initiation. The 1:1 observation of Resident #20 was completed by licensed nursing staff, or by CNA and supervised by licensed nursing staff to ensure it was done correctly. -Resident #20 was discharged to a behavioral hospital at 11:05 a.m. on 8/23/18. -Interviews with 3 CNAs and 1 LVN indicated they were able to identify the components of the in-services provided and had received in-services including: 1) recognizing inappropriate sexual behavior; 2) reporting inappropriate sexual behavior to facility management; and 3) how to do 1:1 observation with Resident #20. On 08/23/18 at 12:10 p.m., the facility director was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at pattern for potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A daily census report dated 8/20/18 indicated five female residents resided on the secure unit.

Based on observation, interview, and record review the facility failed to implement written policies and procedures that prevented abuse of residents for 2 of 7 residents reviewed for abuse. (Resident #20 and #41) The facility did not prevent resident to resident abuse when Resident #20, who had a history of [REDACTED].#41, was found with Resident #41 in his bed with her shirt up as he was taking his pants off next to her. Resident #20 started making sexually inappropriate comments towards Resident #41 on 8/8/18 and was ordered medication to decrease his libido; however, it was ineffective and he continued the behavior. Resident #20 made mulitple attempts to lure Resident #41 into his room and continued making lude sexual comments to the resident. No new interventions were attempted. An Immediate Jeopardy was identified on 8/22/18. The Immediate Jeopardy was removed on 8/23/18; however, the facility remained out of compliance at a pattern of potential for more than minimal harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 5 female residents who resided on the secure unit at risk for abuse. Findings included: An abuse policy dated 7/10/18 indicated the purpose of the policy was to ensure that each resident had the right to be free from any type of abuse or neglect. 1. Physician orders [REDACTED].#41, admitted [DATE], was a [AGE] year old female with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #41 was rarely or never understood, had short and long term memory problems, and was assessed by staff to have moderately impaired skills for decision making. Resident #41 needed extensive assistance for transfers, dressing, eating, and toileting, and was totally dependent on staff for bathing. Resident #41 did not require the use of mobility devices. A care plan dated 6/27/18 indicated Resident #41's focus areas included impaired cognitive function, communication problem related to disorganized speech, and an inability to make needs known. The care plan indicated Resident #41 was rarely understood, and sometimes understood simple and direct communication. Resident #41 paced and resisted care. The care plan indicated Resident #41 wandered and was at risk of elopement related to dementia. Resident #41 resided on the secure unit, where she paced and wandered throughout the day and night. 2. Physician orders [REDACTED].#20, admitted [DATE], was an [AGE] year old male with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#20 was to receive [MEDICATION NAME] (causes decreased libido) 5 mg daily due to sexual behaviors. A care plan dated 7/10/18 indicated a focus area for Resident #20 included communication deficit related to poor hearing and disorganized thinking, impaired cognitive function, and he was an elopement risk. The care plan indicated Resident #20 had a history of [REDACTED]. It did not address any inappropriate sexual behaviors. A review of nursing notes for Resident #20 included: *8/1/18 1:30 p.m., by LVN R - Resident #20 returned to facility from a local behavioral hospital. *8/2/18 8:46 p.m., by LVN S - The resident wandered about on the secure unit with a walker, very talkative, and stated I need to have sex. Informed the resident that his wife was asleep, and resident stated, well maybe you can help me out. Nurse attempted to redirect the resident and change the subject, it worked briefly, [MEDICATION NAME] given as ordered. *8/8/18 8:27 a.m., by LVN A - Resident noted to have increased sexual activity towards another resident noted (resident not identified). Resident #20 saw the female resident down the hall walking by his room and cat called (make a [MEDICATION NAME], shout, or comment of a sexual nature to a woman passing by) the other resident. Physician notified, staff aware. *8/8/18 6:16 p.m. by LVN A - New order [MEDICATION NAME] 5 mg one by mouth every day for noted sexual behavior. The most recent MDS dated [DATE] indicated Resident #20 had a severe cognitive impairment and required supervision only for most ADLs. The assessment indicated no behavioral symptoms were present. A TAR dated (MONTH) (YEAR) indicated Resident #20 received [MEDICATION NAME] 5 mg daily from 8/9/18 through 8/23/18. There was no indication if the medication was effective noted on the TAR. During an interview on 8/21/18 at 2:25 p.m., CNA E said Resident #41 wandered all the time. She said Resident #20 started saying inappropriate things to her such as come in here and let me show you what I have or that he wanted sex. CNA E said there was one time that she and CNA D were in another resident's room and when they came out, neither Resident #20 nor Resident #41 were visible and the door to Resident #20's room was shut. She said when she went in Resident #20's room, Resident #41 was lying in bed with her shirt pulled up midway and Resident #20 was taking his pants off next to Resident #41. CNA E said when she entered Resident #20's room he said, you caught me I guess you knew what I was about to do. CNA E could not recall the date and time of the event, nor which nurse she notified. During an interview on 8/21/18 at 2:17 p.m., CNA D said Resident #20 had been trying to get Resident #41 in his room with him. CNA D said she and the other CNAs tried to keep them separated. CNA D said Resident #41 would start to go into Resident #20's room, but they caught her before she could walk in the room. CNA D said she saw Resident #41 in Resident #20's room before, but I got her out. CNA D said she told all of the nurses who worked on the 2-10 shift about Resident #20's behavior. CNA D said Resident #20 asked her one night if she ever had a man jump on her before. During an interview on 8/21/18 at 2:08 p.m., CNA C said she heard about the incidents from CNA D and CNA E. She said the times Resident #20 would get Resident #41 into his room was when the CNAs were in another resident's room. CNA C said Resident #20 was sneaky and would do something in a split second. She said the reason he was on the secure unit was because he had a history of [REDACTED]. During an interview on 8/22/18 at 1:09 p.m., CNA C said she witnessed Resident #20 make sexually inappropriate statements to Resident #41. CNA C said one time Resident #20 was not aware that she was behind him when he was walking behind Resident #41 and whispered to the resident, I sure do like that pussy. CNA C said she witnessed Resident #20 try to lure Resident #41 into his room. CNA C said Resident #20 would stand in the doorway of his room and whisper to Resident #41 to try and make her come into his room. CNA C said she had seen Resident #20 do that 15-20 times. CNA C said she reported it to the nurse every day that it happened. She said she reported it to the nurse at least five times of Resident #20's sexual behavior towards Resident #41. CNA C said she reported it to LVN A and also to an unidentified LVN. During an interview on 8/21/18 at 1:25 p.m., LVN A said Resident #20 had dementia, and had been having sexual behaviors toward Resident #41. LVN A said Resident #20 would say explicit things to Resident #41, such as I want that pussy. LVN A said when Resident #20 was walking in the hall he would try to get Resident #41 to come into his room. LVN A said once she was told by CNA C that Resident #20 and Resident #41 had swapped shirts or something, and that the physician started Resident #20 on [MEDICATION NAME] to see if it would help with the behaviors. LVN A said this morning Resident #20 said, I want that pussy to Resident #41 as she walked by his room. During an interview on 8/21/18 at 12:36 p.m., CNA C said Resident #20 had sexual behaviors toward Resident #41. CNA C said Resident #20 tried to get Resident #41 into his room and had been successful twice. CNA C said she heard about it from other staff. CNA C said once when they found Resident #20, Resident #41 was lying in his bed, and another time he had taken off her shirt and put his sleep shirt onto her. CNA C said CNA E indicated she reported it to the nurse. During an interview on 8/21/18 at 4:30 p.m., CNA H said Resident #20 was known to try to get Resident #41 to come into his room. During an interview on 8/21/18 at 2:47 p.m., the DON said she first learned of Resident #20's sexually inappropriate behavior when she read the nursing note in his record dated 8/8/18. The DON said there were no incident reports regarding Resident #20's sexual behaviors, and that no one had reported it to her. The DON said Resident #20's physician prescribed [MEDICATION NAME] (used to treat benign enlargement of the prostate) to address the sexual behavior, but she was uncertain if it had been effective. The DON said no other interventions to address Resident #20's inappropriate sexual behaviors towards Resident #41 were implemented. The DON said she was not aware of any inappropriate physical contact by Resident #20 toward any resident. The DON said the progress note dated 8/8/18 referred to Resident #20 and Resident #41. The DON said she had no knowledge of the incident regarding the alleged incident described by CNA E. She said if it occurred, there should have been an incident report, and that it should have been reported to the state. During an interview on 8/22/18 at 1:50 p.m., the DON said CNA E could not recall the day or time the incident with Resident #41 being found in bed in Resident #20's room, but CNA E remembered working with CNA F during the 2-10 shift. The DON said CNA E and CNA F worked together most recently on 8/13/18. The DON said nurses who were working that day had no knowledge of the incident. The DON said there were no interventions regarding sexually inappropriate behavior on Resident #20's care plan. The administrator was informed on 08/22/18 at 4:20 p.m. that there was an Immediate Jeopardy situation due to the above failures. The facility's plan of removal was accepted on 8/22/18 at 6:45 p.m. and included: *The physician was notified with orders received to refer Resident #20 to a behavior Hospital *Behavior hospital contacted. *Family members notified for both residents *CNA E was suspended 8/22/18 pending investigation regarding CNA not following facility policy on reporting abuse or neglect. *Staff educated on facility policy and procedures for prompt reporting of Abuse/Neglect, started 8-21-18 with no one working the floor until in-serviced . *Resident #20 was placed on one on one supervision until alternate placement found. One on One would be with a staff member within ten feet and eye sight, staying with the resident at all times. Facility to document monitoring on a fifteen minute paper monitoring sheet Resident #41 showing no signs or symptoms of emotional distress *All female residents on secured Hall were given head to toe assessments with no suspicious bruises noted. *Emergency Q.A. meeting held with Medical Director 8-22-18. Medical Director suggested looking into other Behavior Hospitals if the first one would not accept Resident #20. *Life satisfaction surveys to be done *Provide additional information through Relias Learning on Sexual Acting Out - Dementia. *Goal was to have Resident #20 discharged by end of business day 8-23-18, facility Social Worker was reaching out to other Behavior Hospitals looking for placement *Attached a one on one schedule for Resident #20 through Friday (8/24/18). On 08/23/18, the surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: -During observations, Resident #20 was placed on 1:1 observation by facility staff starting at 4:20 p.m. on 8/22/18 when the IJ was called. -Review of documentation indicated the 1:1 observation of Resident #20 had been continuous since initiation. The 1:1 observation of Resident #20 was completed by licensed nursing staff, or by CNA and supervised by licensed nursing staff to ensure it was done correctly. -Resident #20 was discharged to a behavioral hospital at 11:05 a.m. on 8/23/18. -Interviews with 3 CNAs and 1 LVN indicated they were able to identify the components of the in-services provided and had received in-services including: 1) recognizing inappropriate sexual behavior; 2) reporting inappropriate sexual behavior to facility management; and 3) how to do 1:1 observation with Resident #20. On 08/23/18 at 12:10 p.m., the facility director was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at pattern for potential more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A daily census report dated 8/20/18 indicated five female residents resided on the secure unit.

Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision for 2 of 7 residents reviewed for supervision (Residents #s 20 and 41). The facility did not provide adequate supervision to prevent resident to resident abuse when Resident #20, who had a history of [REDACTED].#41, was found with Resident #41 in his bed with her shirt up as he was taking his pants off next to her. Resident #20 started making sexually inappropriate comments towards Resident #41 on 8/8/18 and was ordered medication to decrease his libido; however, it was ineffective and he continued the behavior. Resident #20 made mulitple attempts to lure Resident #41 into his room and continued making lude sexual comments to the resident. No new interventions were attempted. An Immediate Jeopardy was identified on 8/22/18. The Immediate Jeopardy was removed on 8/23/18; however, the facility remained out of compliance at a pattern of potential for more than minimal harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 5 female residents who resided on the secure unit at risk for abuse. Findings included: 1. Physician orders [REDACTED].#41, admitted [DATE], was a [AGE] year old female with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #41 was rarely or never understood, had short and long term memory problems, and was assessed by staff to have moderately impaired skills for decision making. Resident #41 needed extensive assistance for transfers, dressing, eating, and toileting, and was totally dependent on staff for bathing. Resident #41 did not require the use of mobility devices. A care plan dated 6/27/18 indicated Resident #41's focus areas included impaired cognitive function, communication problem related to disorganized speech, and an inability to make needs known. The care plan indicated Resident #41 was rarely understood, and sometimes understood simple and direct communication. Resident #41 paced and resisted care. The care plan indicated Resident #41 wandered and was at risk of elopement related to dementia. Resident #41 resided on the secure unit, where she paced and wandered throughout the day and night. 2. Physician orders [REDACTED].#20, admitted [DATE], was an [AGE] year old male with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#20 was to receive [MEDICATION NAME] (causes decreased libido) 5 mg daily due to sexual behaviors. A care plan dated 7/10/18 indicated a focus area for Resident #20 included communication deficit related to poor hearing and disorganized thinking, impaired cognitive function, and he was an elopement risk. The care plan indicated Resident #20 had a history of [REDACTED]. It did not address any inappropriate sexual behaviors. A review of nursing notes for Resident #20 included: *8/1/18 1:30 p.m., by LVN R - Resident #20 returned to facility from a local behavioral hospital. *8/2/18 8:46 p.m., by LVN S - The resident wandered about on the secure unit with a walker, very talkative, and stated I need to have sex. Informed the resident that his wife was asleep, and resident stated, well maybe you can help me out. Nurse attempted to redirect the resident and change the subject, it worked briefly, [MEDICATION NAME] given as ordered. *8/8/18 8:27 a.m., by LVN A - Resident noted to have increased sexual activity towards another resident noted (resident not identified). Resident #20 saw the female resident down the hall walking by his room and cat called (make a [MEDICATION NAME], shout, or comment of a sexual nature to a woman passing by) the other resident. Physician notified, staff aware. *8/8/18 6:16 p.m. by LVN A - New order [MEDICATION NAME] 5 mg one by mouth every day for noted sexual behavior. The most recent MDS dated [DATE] indicated Resident #20 had a severe cognitive impairment and required supervision only for most ADLs. The assessment indicated no behavioral symptoms were present. A TAR dated (MONTH) (YEAR) indicated Resident #20 received [MEDICATION NAME] 5 mg daily from 8/9/18 through 8/23/18. There was no indication if the medication was effective noted on the TAR. During an interview on 8/21/18 at 2:25 p.m., CNA E said Resident #41 wandered all the time. She said Resident #20 started saying inappropriate things to her such as come in here and let me show you what I have or that he wanted sex. CNA E said there was one time that she and CNA D were in another resident's room and when they came out, neither Resident #20 nor Resident #41 were visible and the door to Resident #20's room was shut. She said when she went in Resident #20's room, Resident #41 was lying in bed with her shirt pulled up midway and Resident #20 was taking his pants off next to Resident #41. CNA E said when she entered Resident #20's room he said, you caught me I guess you knew what I was about to do. CNA E could not recall the date and time of the event, nor which nurse she notified. During an interview on 8/21/18 at 2:17 p.m., CNA D said Resident #20 had been trying to get Resident #41 in his room with him. CNA D said she and the other CNAs tried to keep them separated. CNA D said Resident #41 would start to go into Resident #20's room, but they caught her before she could walk in the room. CNA D said she saw Resident #41 in Resident #20's room before, but I got her out. CNA D said she told all of the nurses who worked on the 2-10 shift about Resident #20's behavior. CNA D said Resident #20 asked her one night if she ever had a man jump on her before. During an interview on 8/21/18 at 2:08 p.m., CNA C said she heard about the incidents from CNA D and CNA E. She said the times Resident #20 would get Resident #41 into his room was when the CNAs were in another resident's room. CNA C said Resident #20 was sneaky and would do something in a split second. She said the reason he was on the secure unit was because he had a history of [REDACTED]. During an interview on 8/22/18 at 1:09 p.m., CNA C said she witnessed Resident #20 make sexually inappropriate statements to Resident #41. CNA C said one time Resident #20 was not aware that she was behind him when he was walking behind Resident #41 and whispered to the resident, I sure do like that pussy. CNA C said she witnessed Resident #20 try to lure Resident #41 into his room. CNA C said Resident #20 would stand in the doorway of his room and whisper to Resident #41 to try and make her come into his room. CNA C said she had seen Resident #20 do that 15-20 times. CNA C said she reported it to the nurse every day that it happened. She said she reported it to the nurse at least five times of Resident #20's sexual behavior towards Resident #41. CNA C said she reported it to LVN A and also to an unidentified LVN. During an interview on 8/21/18 at 1:25 p.m., LVN A said Resident #20 had dementia, and had been having sexual behaviors toward Resident #41. LVN A said Resident #20 would say explicit things to Resident #41, such as I want that pussy. LVN A said when Resident #20 was walking in the hall he would try to get Resident #41 to come into his room. LVN A said once she was told by CNA C that Resident #20 and Resident #41 had swapped shirts or something, and that the physician started Resident #20 on [MEDICATION NAME] to see if it would help with the behaviors. LVN A said this morning Resident #20 said, I want that pussy to Resident #41 as she walked by his room. During an interview on 8/21/18 at 12:36 p.m., CNA C said Resident #20 had sexual behaviors toward Resident #41. CNA C said Resident #20 tried to get Resident #41 into his room and had been successful twice. CNA C said she heard about it from other staff. CNA C said once when they found Resident #20, Resident #41 was lying in his bed, and another time he had taken off her shirt and put his sleep shirt onto her. CNA C said CNA E indicated she reported it to the nurse. During an interview on 8/21/18 at 4:30 p.m., CNA H said Resident #20 was known to try to get Resident #41 to come into his room. During an interview on 8/21/18 at 2:47 p.m., the DON said she first learned of Resident #20's sexually inappropriate behavior when she read the nursing note in his record dated 8/8/18. The DON said there were no incident reports regarding Resident #20's sexual behaviors, and that no one had reported it to her. The DON said Resident #20's physician prescribed [MEDICATION NAME] (used to treat benign enlargement of the prostate) to address the sexual behavior, but she was uncertain if it had been effective. The DON said no other interventions to address Resident #20's inappropriate sexual behaviors towards Resident #41 were implemented. The DON said she was not aware of any inappropriate physical contact by Resident #20 toward any resident. The DON said the progress note dated 8/8/18 referred to Resident #20 and Resident #41. The DON said she had no knowledge of the incident regarding the alleged incident described by CNA E. She said if it occurred, there should have been an incident report, and that it should have been reported to the state. During an interview on 8/22/18 at 1:50 p.m., the DON said CNA E could not recall the day or time the incident with Resident #41 being found in bed in Resident #20's room, but CNA E remembered working with CNA F during the 2-10 shift. The DON said CNA E and CNA F worked together most recently on 8/13/18. The DON said nurses who were working that day had no knowledge of the incident. The DON said there were no interventions regarding sexually inappropriate behavior on Resident #20's care plan. The administrator was informed on 08/22/18 at 4:20 p.m. that there was an Immediate Jeopardy situation due to the above failures. The facility's plan of removal was accepted on 8/22/18 at 6:45 p.m. and included: *The physician was notified with orders received to refer Resident #20 to a behavior Hospital *Behavior hospital contacted. *Family members notified for both residents *CNA E was suspended 8/22/18 pending investigation regarding CNA not following facility policy on reporting abuse or neglect. *Staff educated on facility policy and procedures for prompt reporting of Abuse/Neglect, started 8-21-18 with no one working the floor until in-serviced . *Resident #20 was placed on one on one supervision until alternate placement found. One on One would be with a staff member within ten feet and eye sight, staying with the resident at all times. Facility to document monitoring on a fifteen minute paper monitoring sheet Resident #41 showing no signs or symptoms of emotional distress *All female residents on secured Hall were given head to toe assessments with no suspicious bruises noted. *Emergency Q.A. meeting held with Medical Director 8-22-18. Medical Director suggested looking into other Behavior Hospitals if the first one would not accept Resident #20. *Life satisfaction surveys to be done *Provide additional information through Relias Learning on Sexual Acting Out - Dementia. *Goal was to have Resident #20 discharged by end of business day 8-23-18, facility Social Worker was reaching out to other Behavior Hospitals looking for placement *Attached a one on one schedule for Resident #20 through Friday (8/24/18). On 08/23/18, the surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: -During observations, Resident #20 was placed on 1:1 observation by facility staff starting at 4:20 p.m. on 8/22/18 when the IJ was called. -Review of documentation indicated the 1:1 observation of Resident #20 had been continuous since initiation. The 1:1 observation of Resident #20 was completed by licensed nursing staff, or by CNA and supervised by licensed nursing staff to ensure it was done correctly. -Resident #20 was discharged to a behavioral hospital at 11:05 a.m. on 8/23/18. -Interviews with staff indicated they were able to identify the components of the in-services provided and they had received in-services including: 1) recognizing inappropriate sexual behavior; 2) reporting inappropriate sexual behavior to facility management; and 3) how to do 1:1 observation with Resident #20. On 08/23/18 at 12:10 p.m. the facility director was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at pattern for potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A daily census report dated 8/20/18 indicated five female residents resided on the secure unit.

Based on interview and record review, the facility failed to consult with the physician about a significant change in a resident's physical status for 1 of 6 residents reviewed for physician notification. (Resident #45) The facility did not consult with Resident #45's physician for over 4.5 hours when she experienced difficulty breathing and had an low oxygen saturation (O2 sat) levels. The physician was not notified until Resident #45 was sent emergently to the hospital. An Immediate Jeopardy situation was identified on 3/24/17 at 11:25 a.m. The Immediate Jeopardy was removed on 3/24/17 at 8:00 p.m. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure contributed to Resident #45's continued desaturation and delayed hospitalization . This failure could place 15 residents who use oxygen at risk of not receiving timely emergency medical services. Findings included: Physician orders [REDACTED].#45, admitted [DATE], was a [AGE] year old female with [DIAGNOSES REDACTED]. A physician order [REDACTED].#45 was to receive oxygen at 2 liters per minute (lpm) via nasal cannula at night and as needed for shortness of breath. An MDS assessment dated [DATE] indicated Resident #45 had moderate cognitive impairment, was independent in most ADLs, and experienced occasional urinary incontinence. The most recent MDS dated [DATE] indicated Resident #45's cognitive impairment was unchanged, but she required limited to extensive assistance for most ADLs, experienced frequent urinary incontinence, and required oxygen. A care plan dated 10/21/16 indicated Resident #45 required routine oxygen at night. Interventions included . checking Resident #45's oxygen saturation levels every shift and to report increasing symptoms or signs of distress to physician promptly . A treatment administration record dated February 2017 indicated Resident #45's oxygen saturation level was being measured each shift and her (O2 sat) level was documented as 93% or greater each shift. During an interview on 3/24/17 at 9:58 a.m., CNA B said she was routinely assigned to care for Resident #45. CNA B said on 2/15/17 at about 6:00 a.m., she went into Resident #45's room and she was sick, could not speak and did not want anything to eat. CNA B said she notified LVN A because Resident #45 was looking frail. CNA B said Resident #45 had slept in her recliner the night before and that was unusual for her. CNA B said LVN A came and assessed Resident #45 and said her oxygen was low, but she did not say what the number was. CNA B said when she came back into the room around 9:00 a.m. to 10:00 a.m., the DON was in the room. Nursing progress notes for Resident #45 dated 2/15/17 at 09:00 a.m. - Resident #45's O2 sat level was 46% on room air. The note indicated after giving a breathing treatment, ([MEDICATION NAME][MEDICATION NAME]) and placing her on oxygen at 3 lpm, Resident #45's O2 sat level rose to 65%. The note indicated Resident #45 refused breakfast. Nursing progress notes for Resident #45 dated 2/15/17 at09:15 a.m. - the progress note indicated LVN A notified the DON of Resident #45's O2 sat level of 46%. The note indicated the DON changed #45's mask to a nasal cannula and increased the rate of oxygen from 3 lpm (liters per minute) to 5 lpm and Resident #45's O2 sat level rose to 80% and seemed stable. During an interview on 3/23/17 at 4:45 p.m., LVN A said on 2/15/17 at 9 a.m. Resident #45 had an oxygen O2 sat level of 46% on room air during routine vital signs. LVN A said Resident #45 routinely wears oxygen during the night only. LVN A said she placed Resident #45 on oxygen at 3 lpm via nasal cannula and notified the DON of her condition. LVN A said she and the DON sat Resident #45 up in bed. LVN A said the DON switched Resident #45 from a nasal cannula to an oxygen mask and increased the oxygen rate to 5 lpm. LVN A said Resident #45's O2 sat levels rose to 80-84%. LVN A said she checked on Resident 45 at approximately 12:45 a.m., and her O2 sat level was 48% on 5 lpm via nasal cannula. LVN said she notified the DON at approximately 1:00 p.m. LVN A said the DON assessed Resident #45 and then called Resident #45's daughter to see what she wanted the facility to do. LVN A said Resident #45's daughter wanted her to be sent to the emergency room . LVN A said EMS arrived at the facility at 1:21p.m., and transported Resident #45 to the local emergency room and then to an acute care hospital. LVN A said a normal O2 sat level would be 90% or greater. LVN A said the facility notified Resident #45's physician after she was transported, and that was the first time they had contacted a physician regarding Resident #45's care. LVN A said she should have called the doctor when Resident #45's O2 sat was low at 9:00 a.m. Nursing progress notes for Resident #45 dated 2/15/17 at11:00 a.m. - LVN A checked Resident #45's vital signs and documented blood pressure 121/69, pulse 88, respirations 22 per minute, and temperature of 97.8. A productive cough was noted. No O2 sat level was documented. Nursing progress notes for Resident #45 dated 2/15/17 at12:45 p.m. - LVN A was notified by CNA B that Resident #45 was having difficulty breathing, and vital signs at that time were blood pressure 135/95, pulse 85, respiration 28 per minute, and an O2 sat level of 47% on 5 lpm. A nursing progress note dated 2/16/17 at 1:00 p.m. indicated the DON was notified by LVN A on 2/15/17 at 1:00 p.m. that Resident #45's O2 sat levels were in the 40s again. The DON assessed Resident #45 and noted O2 sat levels in the mid 40's. Bilateral rattles and wheezes were noted on assessment of Resident #45's lungs. The resident was unable to breathe deeply. Abdominal breathing was noted and fingertips slightly cyanotic. The note indicated Resident #45's daughter was contacted by another staff member and that the Resident's daughter made the decision to send Resident #45 to the ER. Nursing progress notes for Resident #45 dated 2/15/17 at1:21 p.m. - Resident #45 was transported to the emergency room . During an interview on 3/23/17 at 5:17 p.m., the DON said she recalled that Resident #45 had low O2 sat levels on the morning of 2/15/17 but she did not remember a specific number. The DON said LVN A reported to her that Resident #45's O2 sat levels had come back up and she was checking on her. The DON said she had switched Resident #45 from a nasal cannula to an oxygen mask. The DON said after lunch LVN A reported to her that Resident #45's O2 sat level had dropped again. The DON said she did not remember the number, but it was low. The DON said she talked to Resident #45's daughter and she wanted the resident to be sent to the emergency room . The DON said she notified the doctor at 2:30 p.m. The DON said a normal O2 sat level would be 90% or greater, and that Resident #45's O2 sat level should have been 90% or greater as well. The DON said the physician should be notified if a resident's O2 sat level is less than 90%. The DON said Resident #45's low oxygen saturation level was first identified at 9:00 a.m., and the physician should have been called at that time. The hospital records indicated dated 2/20/17 indicated Resident #45 was admitted to the acute care hospital on [DATE] for shortness of breath, and discharged on [DATE] with [DIAGNOSES REDACTED]. During an interview on 3/14/17 at 4:45 p.m., Resident #45 said she remembered when she was having difficulty breathing and had to go to the hospital. Resident #45 said I was really sick. I didn't think I was going to make it. A policy for resident examination and assessment, dated December 2011, indicated the physician should be notified of any abnormal vital signs or difficulty breathing. During an interview on 3/24/17 at 11:15 a.m., the nurse consultant said she would expect the physician to be notified if a resident's O2 sat was less than 90%. The website http://www.nonin.com/Normal-Oxygen-Level accessed 04/06/17 indicated the following: An SpO2 of greater than 95% is generally considered to be normal. An SpO2 of 92% or less (at sea level) suggests hypoxemia (low blood oxygen.) A policy for resident examination and assessment, dated December 2011, indicated the physician should be notified of any abnormal vital signs or difficulty breathing. During an interview on 3/24/17 at 11:50 a.m. the executive director and nurse consultant were notified an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on 3/24/17 at 2:35 p.m., and included: .1. LVN A was suspended on 3/24/17 pending investigation regarding critical thinking assessment skills 2. All nurses will be educated on physician notification regarding resident changes in condition prior to working their next shift 3. DON will have one on one education from the regional nurse consultant on recognizing changes in condition or residents and notification of physician, or initiating an emergency response. 4. All residents will be assessed today to ensure changes in condition have been reported to the physician 5. The facility will implement a policy that a resident's physician will be notified if oxygen saturation levels drop below 90% unless the physician order [REDACTED]. On 3/24/17, the investigators confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: In-service documentation indicated 16 nurses were in-serviced regarding changes in condition, abnormal vital signs, and physician notification. A Disciplinary Action Record dated 3/24/17 indicated LVN A was suspended for failure to notify the physician upon resident change in condition. In-service documentation dated 3/24/17 indicated the DON received an in-service on code procedures, procedures for monitoring changes in condition, holding staff accountable to acceptable standard of care, and need to notify physician on changes in resident condition. An untitled policy dated 3/24/17 indicated physician should be notified for any resident having an oxygen saturation level of less than 90% unless indicated otherwise in the physician order. Nursing documentation indicated all residents were assessed for changes in condition needing physician notification. Three nurses on duty were interviewed and said they had received in-service training on 3/24/17 and were able to answer questions regarding when to notify the physician, changes in resident condition, and oxygen saturation levels. During an interview on 3/24/17 at 8:00 p.m., the nurse consultant, executive director, and chief clinical officer were notified the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A physician order [REDACTED].

Based on interview and record review, the facility failed to ensure 1 of 6 residents reviewed for change in condition received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident ' s comprehensive assessment and plan of care. (Resident #45) The facility did not assess, frequently monitor, or notify the physician when Resident #45 experienced difficulty breathing and had an low oxygen saturation levels (O2 sats). Resident #45 was sent emergently to the hospital after she had extremely low O2 sats for over 4 hours. An Immediate Jeopardy situation was identified on 3/24/17 at 11:25 a.m. The Immediate Jeopardy was removed on 3/24/17 at 8:00 p.m. The facility remained out of compliance at isolated of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure contributed to Resident #45's continued desaturation and delayed hospitalization . This failure could place 15 residents who use oxygen at risk of not receiving timely emergency medical services. Findings included: Physician orders [REDACTED].#45, admitted [DATE], was a [AGE] year old female with [DIAGNOSES REDACTED]. A physician order [REDACTED].#45 was to receive oxygen at 2 liters per minute (lpm) via nasal cannula at night and as needed for shortness of breath. An MDS assessment dated [DATE] indicated Resident #45 had moderate cognitive impairment, was independent in most ADLs, and experienced occasional urinary incontinence. The most recent MDS dated [DATE] indicated Resident #45's cognitive impairment was unchanged, but she required limited to extensive assistance for most ADLs, experienced frequent urinary incontinence, and required oxygen. A care plan dated 10/21/16 indicated Resident #45 required routine oxygen at night. Interventions included . checking Resident #45's oxygen saturation levels every shift and to report increasing symptoms or signs of distress to physician promptly . A treatment administration record dated February 2017 indicated Resident #45's oxygen saturation level was being measured each shift and her (O2 sat) level was documented as 93% or greater each shift. During an interview on 3/24/17 at 9:58 a.m., CNA B said she was routinely assigned to care for Resident #45. CNA B said on 2/15/17 at about 6:00 a.m., she went into Resident #45's room and she was sick, could not speak and did not want anything to eat. CNA B said she notified LVN A because Resident #45 was looking frail. CNA B said Resident #45 had slept in her recliner the night before and that was unusual for her. CNA B said LVN A came and assessed Resident #45 and said her oxygen was low, but she did not say what the number was. CNA B said when she came back into the room around 9:00 a.m. to 10:00 a.m., the DON was in the room. Nursing progress notes for Resident #45 dated 2/15/17 at 09:00 a.m. - Resident #45's O2 sat level was 46% on room air. The note indicated after giving a breathing treatment, ([MEDICATION NAME][MEDICATION NAME]) and placing her on oxygen at 3 lpm, Resident #45's O2 sat level rose to 65%. The note indicated Resident #45 refused breakfast. Nursing progress notes for Resident #45 dated 2/15/17 at09:15 a.m. - the progress note indicated LVN A notified the DON of Resident #45's O2 sat level of 46%. The note indicated the DON changed #45's mask to a nasal cannula and increased the rate of oxygen from 3 lpm (liters per minute) to 5 lpm and Resident #45's O2 sat level rose to 80% and seemed stable. During an interview on 3/23/17 at 4:45 p.m., LVN A said on 2/15/17 at 9 a.m. Resident #45 had an oxygen O2 sat level of 46% on room air during routine vital signs. LVN A said Resident #45 routinely wears oxygen during the night only. LVN A said she placed Resident #45 on oxygen at 3 lpm via nasal cannula and notified the DON of her condition. LVN A said she and the DON sat Resident #45 up in bed. LVN A said the DON switched Resident #45 from a nasal cannula to an oxygen mask and increased the oxygen rate to 5 lpm. LVN A said Resident #45's O2 sat levels rose to 80-84%. LVN A said she checked on Resident 45 at approximately 12:45 a.m., and her O2 sat level was 48% on 5 lpm via nasal cannula. LVN said she notified the DON at approximately 1:00 p.m. LVN A said the DON assessed Resident #45 and then called Resident #45's daughter to see what she wanted the facility to do. LVN A said Resident #45's daughter wanted her to be sent to the emergency room . LVN A said EMS arrived at the facility at 1:21p.m., and transported Resident #45 to the local emergency room and then to an acute care hospital. LVN A said a normal O2 sat level would be 90% or greater. LVN A said the facility notified Resident #45's physician after she was transported, and that was the first time they had contacted a physician regarding Resident #45's care. LVN A said she should have called the doctor when Resident #45's O2 sat was low at 9:00 a.m. Nursing progress notes for Resident #45 dated 2/15/17 at11:00 a.m. - LVN A checked Resident #45's vital signs and documented blood pressure 121/69, pulse 88, respirations 22 per minute, and temperature of 97.8. A productive cough was noted. No O2 sat level was documented. Nursing progress notes for Resident #45 dated 2/15/17 at12:45 p.m. - LVN A was notified by CNA B that Resident #45 was having difficulty breathing, and vital signs at that time were blood pressure 135/95, pulse 85, respiration 28 per minute, and an O2 sat level of 47% on 5 lpm. A nursing progress note dated 2/16/17 at 1:00 p.m. indicated the DON was notified by LVN A on 2/15/17 at 1:00 p.m. that Resident #45's O2 sat levels were in the 40s again. The DON assessed Resident #45 and noted O2 sat levels in the mid 40's. Bilateral rattles and wheezes were noted on assessment of Resident #45's lungs. The resident was unable to breathe deeply. Abdominal breathing was noted and fingertips slightly cyanotic. The note indicated Resident #45's daughter was contacted by another staff member and that the Resident's daughter made the decision to send Resident #45 to the ER. Nursing progress notes for Resident #45 dated 2/15/17 at1:21 p.m. - Resident #45 was transported to the emergency room . During an interview on 3/23/17 at 5:17 p.m., the DON said she recalled that Resident #45 had low O2 sat levels on the morning of 2/15/17 but she did not remember a specific number. The DON said LVN A reported to her that Resident #45's O2 sat levels had come back up and she was checking on her. The DON said she had switched Resident #45 from a nasal cannula to an oxygen mask. The DON said after lunch LVN A reported to her that Resident #45's O2 sat level had dropped again. The DON said she did not remember the number, but it was low. The DON said she talked to Resident #45's daughter and she wanted the resident to be sent to the emergency room . The DON said she notified the doctor at 2:30 p.m. The DON said a normal O2 sat level would be 90% or greater, and that Resident #45's O2 sat level should have been 90% or greater as well. The DON said the physician should be notified if a resident's O2 sat level is less than 90%. The DON said Resident #45's low oxygen saturation level was first identified at 9:00 a.m., and the physician should have been called at that time. The hospital records indicated dated 2/20/17 indicated Resident #45 was admitted to the acute care hospital on [DATE] for shortness of breath, and discharged on [DATE] with [DIAGNOSES REDACTED]. During an interview on 3/14/17 at 4:45 p.m., Resident #45 said she remembered when she was having difficulty breathing and had to go to the hospital. Resident #45 said I was really sick. I didn't think I was going to make it. A policy for resident examination and assessment, dated December 2011, indicated the physician should be notified of any abnormal vital signs or difficulty breathing. During an interview on 3/24/17 at 11:15 a.m., the nurse consultant said she would expect the physician to be notified if a resident's O2 sat was less than 90%. The website http://www.nonin.com/Normal-Oxygen-Level accessed 04/06/17 indicated the following: An SpO2 of greater than 95% is generally considered to be normal. An SpO2 of 92% or less (at sea level) suggests hypoxemia (low blood oxygen.) A policy for resident examination and assessment, dated December 2011, indicated the physician should be notified of any abnormal vital signs or difficulty breathing. During an interview on 3/24/17 at 11:50 a.m. the executive director and nurse consultant were notified an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on 3/24/17 at 2:35 p.m., and included: .1. LVN A was suspended on 3/24/17 pending investigation regarding critical thinking assessment skills 2. All nurses will be educated on physician notification regarding resident changes in condition prior to working their next shift 3. DON will have one on one education from the regional nurse consultant on recognizing changes in condition or residents and notification of physician, or initiating an emergency response. 4. All residents will be assessed today to ensure changes in condition have been reported to the physician 5. The facility will implement a policy that a resident's physician will be notified if oxygen saturation levels drop below 90% unless the physician order [REDACTED]. On 3/24/17, the investigators confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: In-service documentation indicated 16 nurses were in-serviced regarding changes in condition, abnormal vital signs, and physician notification. A Disciplinary Action Record dated 3/24/17 indicated LVN A was suspended for failure to notify the physician upon resident change in condition. In-service documentation dated 3/24/17 indicated the DON received an in-service on code procedures, procedures for monitoring changes in condition, holding staff accountable to acceptable standard of care, and need to notify physician on changes in resident condition. An untitled policy dated 3/24/17 indicated physician should be notified for any resident having an oxygen saturation level of less than 90% unless indicated otherwise in the physician order. Nursing documentation indicated all residents were assessed for changes in condition needing physician notification. Three nurses on duty were interviewed and said they had received in-service training on 3/24/17 and were able to answer questions regarding when to notify the physician, changes in resident condition, and oxygen saturation levels. During an interview on 3/24/17 at 8:00 p.m., the nurse consultant, executive director, and chief clinical officer were notified the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A physician order [REDACTED].