Every finding on record at Focused Care of Waxahachie

Based on interviews and record review, the facility failed to implement a comprehensive care plan that described the services to be furnished to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 2 of 5 residents (Resident #1 Resident #2) reviewed for care plans. The facility failed to implement interventions for Resident #1 and Resident #2 when it was witnessed by CNA A both residents were calling each other names and cursing at each other while on a smoke break on 08/03/2026.This deficient practice placed residents at risk of not having their individualized needs met and communicated to providers that could result in a decline in physical well-being. Findings included:A record review of Resident #1's face sheet dated 08/14/2026 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses were chronic obstructive pulmonary disease (a long-term lung disease that blocks airflow and make it hard to breathe), anxiety disorder (common mental health conditions that cause intense, ongoing fear, panic, or worry that does not go away and can get worse over time), essential primary hypertension (high blood pressure that has no clear single medical cause), and unspecified dementia (clear sign of brain-based cognitive decline).A record review of Resident #1's care plan, dated 05/20/2026 reflected Resident #1 had a behavior problem that was initiated on 11/12/2025 with no interventions in place for the verbal incident on 08/03/2026.A record review of Resident #1's Quarterly MDS assessment, dated 08/07/2026, reflected Resident #1 had a BIMS score of 15, which indicated cognition was intact. Resident #1's MDS did not indicate any verbal behaviors.A record review of Resident #2's face sheet dated 08/14/2026 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses were major depressive order (lasting sadness), transient cerebral ischemic attack (temporary block of blood flow to part of the brain), type 2 diabetes (chronic condition where the body resists insulin or does not make enough of it), and unspecified epilepsy (recurrent seizure disorder).A record review of Resident #2's care plan, dated 07/22/2026 reflected Resident #2 had a behavior problem r/t low tolerance and was initiated on 07/22/2026 with no interventions in place for the verbal incident on 08/03/2026.A record review of Resident #2's admission MDS assessment, dated 07/20/2026, reflected Resident # 2 had a BIMS score of 13, which indicated cognition was intact. Resident #2's MDS showed verbal behavior symptoms directed towards others.During an interview with the DON on 08/14/2026 at 8:09 PM she stated she was responsible for updating the interventions on the care plans for Resident #1 and Resident #2. The DON stated it was expected for her to update the interventions with the most current date of incidents. The DON stated she just failed to update the interventions and when the interventions were not updated staff would not know what was going on and how to react.During an interview with the ADM on 08/14/2026 at 9:12 PM she stated it was the DON's responsibility to update Resident #1's and Resident #2's behavior interventions on the care plan. The DON stated it was very important to update the behavior interventions. The ADM stated when the care plan was not updated staff would not had known what care to provide.A record review of the facility's care plan policy dated 01/20/2021 last revised 04/25/2021 reflected Every resident will have an individualized interdisciplinary plan of care in place. A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of Admission. The Interdisciplinary Team will continue to develop the plan in conjunction with the RAI (MOS 3.0) and CAAS, completing and conducting Comprehensive Care Plan Meeting and Reviews by day 21 after Admission. The Care Plan is revised every quarter, significant change of condition, Annual or as the resident condition changes on an individualized basis. The Care Plan process is an ongoing review process. The resident's Care Plan will include participation from residents' representatives, external partners PASRR, Hospice, Therapy, Clinicians and not as all-inclusive.

Based on interviews and record review, the facility failed to ensure that allegations involving abuse, neglect, and misappropriation of resident property were reported immediately, but no later than 2 hours after the allegation is made to the State Survey Agency for 2 of 5 residents (Resident #1 and Resident #2) reviewed for verbal abuse.The facility failed to report within 2 hours to the State Survey Agency (HHSC - Health and Human Services Commission) when Resident #1 and Resident # 2 were calling each other names while on a smoke break on 08-03-2026.This failure could place residents at risk for emotional distress.Findings included:A record review of Resident #1's face sheet dated 08/14/2026 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses were chronic obstructive pulmonary disease (a long-term lung disease that blocks airflow and make it hard to breathe), anxiety disorder (common mental health conditions that cause intense, ongoing fear, panic, or worry that does not go away and can get worse over time), essential primary hypertension (high blood pressure that has no clear single medical cause), and unspecified dementia (clear sign of brain-based cognitive decline).A record review of Resident #1's care plan, dated 05/20/2026 reflected Resident #1 had anxiety (common mental health conditions that cause intense, ongoing fear, panic, or worry that does not go away and can get worse over time).A record review of Resident #1's Quarterly MDS assessment, dated 08/07/2026, reflected Resident #1 had a BIMS score of 15, which indicated cognition was intact.A record review of Resident #1's facility investigation report dated 08/04/2026 reflected the ADM was informed there was a verbal altercation between Resident #1 and Resident #2. Resident #1 and Resident #2 were exchanging insults between one another.A record review of Resident #2's face sheet dated 08/14/2026 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses were major depressive order (lasting sadness), transient cerebral ischemic attack (temporary block of blood flow to part of the brain), type 2 diabetes (chronic condition where the body resists insulin or does not make enough of it), and unspecified epilepsy (recurrent seizure disorder).A record review of Resident #2's care plan, dated 07/22/2026 reflected Resident #2's transient cerebral ischemic attack (temporary block of blood flow to part of the brain).A record review of Resident #2's admission MDS assessment, dated 07/20/2026, reflected Resident #2 had a BIMS score of 13, which indicated cognition was intact.A record review of Resident #2's facility investigation report dated 08/04/2026 reflected the ADM was informed there was a verbal altercation between Resident #1 and Resident #2. Resident #1 and Resident #2 were exchanging insults between one another.A record review of Resident # 2's progress note dated 08/04/2026 revealed the DON made the ADM aware that Resident #1 and Resident #2 were noted arguing with each other on 08/03/2026. Resident #1 had responded to Resident #2 by calling her a nappy head bitch.A record review of the facility's provider investigator report dated 08/04/2026 reflected that the facility did not report the alleged verbal abuse within 2 hours to the State Survey Agency (HHSC).A record review of an all staff in-service was conducted and completed by the ADM on 08/04/2026 over abuse.A record review of safe surveys with residents revealed they were conducted by the ADM beginning on 08/04/2026 and was completed on 08/07/2026. The safe surveys results did not indicate any residents had any issues with verbal abuse with any other residents.During an interview with Resident #2 on 08/14/2026 at 11:20 AM Resident #2 stated she was on a smoke break on 08/03/2026 at the outside smoking area when Resident #1 started making fun of her. Resident #2 stated Resident #1 called her a bitch and said her hair was nappy. Resident #2 stated she did not know why Resident #1 called her a bitch and she was upset about it, and she had reported the incident to the ADM. Resident #2 stated she was safe and did not have any issues with abuse or neglect.During an interview with Resident #1 on 08/14/2026 at 12:00 PM Resident #1 stated she just told Resident #2 to not be so mean with the nursing staff. Resident #1 stated Resident #2 started cursing at her and she did not say anything else to Resident #2 or exchanged any curse words. Resident #1 stated she believed Resident #2 got mad and started cursing because she told her to stop being so mean to the nursing staff.During an interview with CNA A on 08/14/2026 at 5:05 PM she stated that Resident #1 and Resident #2 on 08/03/2026 were going back and forth during a smoke break calling each other names and cursing at each other as it was time to go back in. CNA A stated she told Resident #1 to go back in to separate Resident #1 and Resident #2. CNA A stated there was no distress with Resident #1 and Resident #2. CNA stated that Resident #2 had already made the report to the ADM and she knew the protocol of reporting the incident immediately once witnessed. CNA A stated she had been trained on abuse , knew the types, knew the signs, and knew to report to abuse coordinator immediately.During an interview with the ADM on 08/14/2026 at 9:12 PM she stated that Resident #2 had reported the incident the day after on 08/04/2026. The ADM stated it was not explained to her as if it was verbal abuse between Resident #1 and Resident #2. The ADM stated it was told to her that Resident #1 and Resident #2 were going back in forth with each other and no cursing was even mentioned. The ADM stated Resident #2 had never stated Resident #1 had cursed or cursed at each other. The ADM stated that CNA A did not say abuse had occurred with Resident #1 and Resident #2. The ADM stated she started the investigation on 08/04/2026 with interviews, safe surveys with residents, and an in-service over abuse with all nursing staff. The ADM stated she would have made the report to the State within the 2 hours of the incident being reported to her if the incident was told correctly. The ADM stated it was expected for her to make the report to the State and it was important to ensure the report was made to the State to make sure residents were safe.A record review of the facility's abuse policy dated 02/10/2017 and last revised 01/27/2020 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. If the allegation does not involve abuse and the event does not result in serious bodily injury, the allegation should be reported within 24 hours. Allegations or incident of resident-to resident behavior may or may not meet the definition of abuse. Reporting can be done via phone at [PHONE NUMBER] or online via https://apps.hhs.texas.gov/services/crs/incidentforms/SRI/. The abuse coordinator with the Director of Nursing/designee will investigate all allegations and use the appropriate forms to document the investigation and turn it in to HHS within 5 calendar days. Upon completion of an investigation, the Director of Nursing and Administrator will analyze the occurrences, and determine what changes, if any, are needed to prevent further occurrence. All documentation of investigation must be protected and made available upon request.

Based on interview and record review, the facility failed to protect 1 (Resident #1) of 7 residents reviewed for abuse and neglect in that:The facility failed to ensure Housekeeper A was not verbally aggressive with Resident # 1 on 05/22/2026.This failure could place residents at risk of emotional distress and psychosocial harm. Findings included:Record review of Resident #1's admission record dated 05/23/2026 documented a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 diagnoses included: major depressive disorder(mood disorder) essential primary hypertension (high blood pressure), and type 2 diabetes (body resist insulin or cannot produce enough of it).Record review of Resident #1's Quarterly MDS assessment, dated 05/11/2026, revealed the resident had a BIMS score of 15 which indicated the resident was cognitively intact.Record review of Resident #1's care plan, dated 05/23/2026, revealed Resident #1 was care planned for impaired coping r/t situational and social factors (social loss of important relationship, disrupted family life, grief, loneliness, helplessness, or hopelessness).An interview with Resident #1 on 05/23/2026 at 11:27 a.m., stated when Housekeeper A cursed at her it made her upset that Housekeeper A would treat her like that. Resident # 1 stated she immediately went to tell the ADM after the incident because she did not want that to happen to anyone else. Resident # 1 stated the day before yesterday, could not recall the time when she asked Housekeeper A to clean her room after she had finished cleaning another room. Resident # 1 stated Housekeeper A never came to her room. Resident # 1 stated on yesterday time not recalled she saw Housekeeper A in the hallway and she was being sarcastic and said to Housekeeper A, thank you for cleaning my room on yesterday and Housekeeper A asked Resident # 1 what did you just say and Resident # 1 stated she told Housekeeper A again thank you for cleaning my room on yesterday. Resident # 1 stated Housekeeper A stated to her Bitch get your crazy ass away from me. Resident # 1 stated she could not believe Housekeeper A had talked to her that way and she was frustrated and mad at the same time.An interview with Housekeeper A on 05/23/2026 at 1:58 p.m., stated that she did not know when she cursed at Resident #1 it would be abuse. Housekeeper A stated she had been working at the facility for about two weeks, and she had completed training at orientation. Housekeeper A stated Resident # 1 was being funny with her because she was not able to clean her room before her shift had ended. Housekeeper A stated the next day Resident # 1 came to look for her to tell her thank you for cleaning her room, when she had not cleaned her room. Housekeeper A stated she asked Resident # 1 what she just say, and out of frustration she told Resident #1 Bitch get your crazy ass away from me. Housekeeper A stated immediately after the incident that the ADM spoke with her, and she told her what she had told Resident #1 and the ADM told her that she could not talk like that to a resident. Housekeeper A stated she did not hurt Resident #1 and she did not feel it was abuse. Housekeeper A stated the ADM immediately suspended her and she had to immediately leave the facility until further investigation.An interview with the Housekeeping Supervisor on 05/23/2026 at 1:58 p.m., stated that he was not in the facility when the incident occurred with Resident #1 and Housekeeper A yesterday. The Housekeeping Supervisor stated that when he made it to the facility yesterday between 8:30 am or 9:00 am, the ADM advised him that Housekeeper A had verbally abused Resident # 1, and she was suspended until further notice and was asked to leave the facility. The Housekeeping Supervisor stated it was expected for Housekeeper A to have treated Resident #1 with respect and not curse at the resident. The Housekeeping Supervisor stated that the Housekeeper had been trained on abuse and neglect at new hire orientation.An interview with the DON on 05/23/2026 at 4:49 p.m., stated that she was made aware of the incident with Housekeeper A and Resident #1 after Resident # 1 reported to the ADM. The DON stated that it was expected for Housekeeper A not to curse at Resident #1. The DON stated that when there was verbal abuse it could cause feelings being hurt, anger, depression, and decline in health,An interview with the ADM on 05/23/2026 at 5:15 p.m., stated Resident #1 reported to her around 8:30 am on yesterday morning that she asked Housekeeper A to clean her room yesterday and Housekeeper A never came to her room. Resident #1 stated this morning when she saw Housekeeper A , she sarcastically said thank you for cleaning her room yesterday even though Housekeeper A did not clean Resident #1's room. Housekeeper A told Resident #1 to shut the hell up and get out my face you crazy bitch. The ADM stated after the conversation with Resident # 1 she immediately went to find Housekeeper A and brought her int the office. The ADM stated she asked Housekeeper A what she say to Resident #1 and Housekeeper A stated that she told Resident #1 to shut the hell up and get out my face you crazy bitch. The ADM then advised Housekeeper A that she was not to speak to any resident like that and advised Housekeeper A that speaking to Resident #1 like that was verbal abuse. The ADM stated that Housekeeper A stated to her even if residents are yelling, cursing, and talking crazy. The ADM stated she advised the Houskeeper that it was verbal abuse. The ADM stated she immediately told Housekeeper A that she was suspended and to leave the premises immediately. The ADM stated that Housekeeper A will be terminated on Tuesday after corporate return from the holiday. The ADM stated it was expected for Housekeeper A to talk to Resident # 1 with Respect. The ADM stated talking like that to a resident could cause depression and emotional distress.An interview with the Social Worker on 05/23/2026 at 6:28 p.m., stated that she was not in the facility on 05/22/2026 when the incident had occurred with Resident #1 and the Housekeeper. The Social Worker stated she was not aware of the incident, and she was sure that the ADM would notify her of the incident on Monday 05/25/2026.Review of Housekeeper A's personnel file reflected that she was hired on 05/14/2026 and terminated on 05/27/2026. Housekeeper A had received her abuse training at orientation on 05/14/2026 and background had been checked.Review of the facility's investigation dated 05/22/2025 reflected a thorough investigation was completed, and the allegation of verbal abuse was confirmed. Inservice over abuse had began with the facility staff on 05/22/2025. Review of facility's Policy dated 02/01/2017 and revised 01/27/2020 titled Abuse 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. The facility staff will adhere to the policies and procedures and will follow the guidelines in the written policy and procedure. The facility administrator is the appointed Abuse Coordinator, and in his/her absence a designee will be appointed. Abuse is a willful infliction of injury or negligent, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct that would constitute an offense under penal code S 21.08 (indecent exposure) or Penal code chapter 22 (assaultive offenses), sexual harassment, sexual coercion, or sexual assault. Residents will not be subjected to abuse by anyone, including, but not limited to community staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, care taker, friends, or other individuals. This includes physical. verbal. sexual. physical /chemical restraint.

Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 1 facility reviewed for environmental concerns. 1. The facility failed to repair a jagged lifted piece of metal with a pointed edge, which was present to the outside of the door, which opened to go out to the designated smoking area of the facility. 2. The facility failed to repair the magnet which was hanging out of the wall for the facility fire door which lead out of the dining room on the 400 hall. 3. The facility failed to repair or replace the door mechanism cover for the smoking door which lead from the sunroom resulting in exposed wiring and door mechanism at the top of the door. 4. The facility failed to repair or replace the loading dock door trim, which had a jagged piece of metal hanging from the door frame. 5. The facility failed to clean the mechanical lift body of the machine. 6. The facility failed to clean the facility handrails and inside the railing of the facility handrails. 7. The facility failed to clean the resident shower rooms after use. These deficient practices could place residents at risk of injuries and decreased quality of life. In an observation on 4/26/26 at 9:11 AM, of the dining room entrance from the 400 hall, revealed the fire door magnet mechanism hung out of the wall with wiring not connected from a hole approximately twice the size of the fire door magnet in the sheetrock. In an observation on 4/26/26 at 9:15 AM revealed the facility handrails and inside railing of the handrail leading from the dining room into the 400 hallway revealed trash, debris, a screw, popsicle stick, and what appeared to be melted and dried ice cream, pink and white in color. Further observation revealed a dried brown substance on the wall right above the handrail and dripped down into the inside railing. In an observation on 4/26/26 at 9:18 AM of facility loading dock door frame revealed a jagged metal door trim broke and pulled loose from door frame. In an observation on 4/26/26 at 9:37 AM revealed the door mechanism cover for the smoking door which lead from the sunroom was missing resulting in exposed wiring and door mechanism at the top of door. In an observation on 4/26/26 at 9:40 AM, of the facility mechanical lift in the hallway revealed the mechanical lift body of the machine was covered with dried dirt grime and debris on the arm mechanism of the lift, on the bottom legs of the lift, and on the lift's main body frame. In an observation on 4/26/26 at 9:43 AM, of facility shower room revealed the shower room floor was dirty with dried debris on floor, 3 dirty dry washcloths on floor, and a bucket with dried dirty washcloth hung out of the bucket. In an observation on 04/26/26 at 2:00 PM revealed the back of the facility door, which lead out to the designated smoking area, had a lifted jagged piece of metal with a pointed edge. In an observation on 4/28/26 at 8:28 AM, of the facility 600 hall handrails and handrail railing revealed a used q-tip in the railing and dried brown and red food like appearing substance. In an interview on 04/26/26 at 2:45 PM, CNA D stated she did not know the door in the facility that went out to the smoking area had a jagged piece of metal with a pointed edge on the outside part of the door just below the doorknob. She stated if a resident were to grab the door or rubbed their skin across the area where the jagged metal was, it could have caused a skin tear. In an interview on 04/27/26 at 11:34 AM, CNA E stated he stated she did not know the door in the facility that went out to the smoking area had a jagged piece of metal with a pointed edge on the outside part of the door just below the doorknob. She stated if a resident were to grab the door or rubbed their skin across the area where the jagged metal was, it could have caused harm and they could have gotten hurt. She stated metal should not have been there because the residents used that door a lot and they could have gotten hurt. In an interview on 04/27/26 at 11:56 AM, LVN C stated she did not know the door in the facility that went out to the smoking area had a jagged piece of metal with a pointed edge on the outside part of the door just below the doorknob. She stated she believed they were waiting on a part to fix the door that allowed residents to use the push button to go in and out. She stated for now the residents had to open and close the door manually. She stated if a resident grabbed the door or rubbed their skin across the area where the jagged metal was, it could have caused a laceration or skin tear. In an interview on 04/27/26 at 12:25 PM, RN A saidshe did not know the door in the facility that went out to the smoking area had a jagged piece of metal with a pointed edge on the outside part of the door just below the doorknob. She stated if a resident grabbed the door or rubbed their skin across the area where the jagged metal was, it could have caused a resident to get an injury or skin tear and could have harmed the resident. In an interview on 04/27/26 at 1:10 PM, the ADM stated she did not know the door in the facility that went out to the smoking area had a jagged piece of metal with a pointed edge on the outside part of the door just below the doorknob. She stated if a resident were to have grabbed the door or rubbed their skin across the area where the jagged metal was, it could have caused a cut or resident injury. In an interview on 04/28/26 at 12:16 PM, the MTS stated he was not aware of the jagged piece of metal with a pointed edge that was bent up on the back of the smoking door. He stated the door had been automatic and they had some complications with the door so they had to fix it, so it had to be opened and closed manually. He stated they ordered a part for the door to fix it so it would open automatically again. He stated he was not aware of any incidents that had happened with the door or any injuries occurring. He stated if there was a lifted piece of jagged metal on the door and a resident rubbed their skin on it they could have gotten injured. In an interview on 04/28/26 at 12:32 PM, the DON stated she did not know the door in the facility that went out to the smoking area had a jagged piece of metal with a pointed edge on the outside part of the door just below the doorknob. She stated if a resident had grabbed the door or rubbed their skin across the area where the jagged metal was, it could have caused a resident to get a cut. In an interview on 4/28/26 at 12:57 PM with MTS stated it was the expectation to try to complete repair issues the day they were submitted unless parts were required that needed to be ordered. The MTS stated if parts needed to be ordered then repairs were completed once the needed parts came in. The MTS stated the facility staff put any maintenance requests or needs in the maintenance log that was at each of the nurse's station. The MTS stated he checked the logs daily if possible but at a minimum of several times a week. The MTS stated he was responsible for completing maintenance requests and building repairs. The MTS stated it could potentially negatively affect a resident if building repairs were not completed. The MTS stated when showed pictures of the back loading dock door, dining room fire door magnet, and door cover mechanism for the sunroom smoking door that he was unaware of these repairs needing to be made and none of these items had been logged into the maintenance log binder. MTS stated the facility staff who found the item needing repair are responsible for entering the repair request into the maintenance binder. In an interview on 4/28/26 at 1:24 PM, HK stated his expectation for facility cleanliness was the building be kept clean and to keep the residents' rooms cleaned. HK stated he received hands on training from his supervisor for the floor tech position and for the housekeeper position, he shadowed the lead housekeeper for several days before being assigned duties on his own. HK stated he was trained to clean the handrails and inside railing when he worked the position of the floor tech. HK stated there were floor techs scheduled for all 7 days of the week. HK stated sanitizer wipes were used to clean the handrails and inside the railing of the handrails. HK stated it was the responsibility of the floor tech to clean the handrails. HK stated it could negatively impact resident if the handrails were not cleaned because the residents could become sick from the spread of germs. HK stated it was the responsibility of housekeeping to clean the resident shower rooms weekly. HK stated the process was to pick up any trash, mop the walls down with cleaner, and then to wipe the walls down with sanitizer wipes after they were cleaned from any soil. HK stated it could negatively affect residents if the shower rooms were not kept clean because of infection risks. HK stated that it was his first day back on shift at the facility since he only works PRN currently and he was unsure of who had recently been on shift or was responsible for ensuring the shower rooms and handrails had been cleaned. In an interview on 4/28/26 at 1:36 PM, HKS stated it was his expectation the facility be kept clean from top to bottom and all public areas and resident rooms. The HKS stated handrails and inside railings were cleaned once a week by housekeeping. The HKS stated it could negatively affect a resident if the handrails and inside of railing were not cleaned because of infection. The HKS stated the shower rooms were cleaned by housekeeping and by CNAs both. The HKS stated after the CNAs completed showers they picked up all linen used and any trash. The HKS stated housekeeping washed the walls with the chemical soap sanitizer and scrubbed the walls with a scrub brush then rinsed with water and wiped down with a dry towel weekly and typically this was completed on the weekends. The HKS stated yes, it could negatively affect a resident if shower rooms were not kept clean because of bacteria risk. In an interview on 4/28/26 at 2:38 PM, LVN H stated for any building repairs the requests were put into the maintenance log binder at the nurse station. LVN H stated the MTS checked the book and then completed the needed repairs. LVN H stated nurses and CNAs were responsible for cleaning the mechanical lift after each resident. LVN H stated sanitizer wipes were used to clean the mechanical lift. LVN H stated housekeeping was responsible for cleaning the facility which included the handrails and the inside of the railing. LVN H stated it could negatively affect a resident if the facility was not kept clean because of infection and bacteria. LVN H stated CNAs were responsible for cleaning the shower rooms after use with each resident. LVN H stated it could negatively affect the resident if the shower rooms were not cleaned because of bacteria. In an interview on 4/28/26 at 2:48 PM, CNA D stated that if the facility needed any repairs she would report it to the ADM. CNA D stated it was the responsibility of MTS to complete facility repairs. CNA D stated it was the responsibility of HK to keep the facility common areas and resident rooms clean. CNA D stated she was unsure who was responsible for cleaning the mechanical lift. CNA D stated if she needed to use the lift that she would clean it with sanitizer wipes prior to use if the lift appeared dirty. CNA D stated the shower rooms are cleaned by CNA staff and HK staff. CNA D stated that after each resident shower is completed that the CNA picks up any used towels and trash and does a general clean up between residents. CNA D stated that HK clean the showers weekly to sanitize. In an interview on 4/28/26 at 3:00 PM, ADM stated it was her expectation that any facility repair request be communicated via the maintenance log repair binder unless it was an emergency then to call the MTS or ADM. ADM stated repairs are completed the next day unless parts are needed to complete the repair then as soon as parts come in the repair is completed. ADM stated MTS is responsible for checking the maintenance log binder daily and completing facility repairs. ADM stated that it was her expectation that the facility be cleaned daily. ADM stated that it was HKS responsibility for ensuring the facility was kept clean. ADM stated that the handrails are cleaned daily. ADM stated that it was her expectation that the mechanical lift be cleaned when it was soiled and after each resident use. ADM stated she was unsure of the cleaning requirements for the mechanical lift, but it would be to look at the policy and the manufacture guidelines. ADM stated it was the responsibility of the nursing staff to clean the mechanical lift. ADM stated it was her expectation the resident shower rooms be cleaned after each resident by the nursing staff and daily by HK staff. ADM stated it could negatively affect the residents if the facility's appearance and cleanliness was not maintained because of possible injury or infection. In an interview on 4/28/26 at 3:30 PM, DON stated it was her expectation that any facility repairs be completed in a timely manner. DON stated that when repairs are needed the facility staff put the repair requests into the maintenance repair log binder. MTS then checks the binder and completes any requests and denotes them in the binder when the request was completed. DON stated MTS was responsible for completing facility repair requests and general facility maintenance. DON stated it could negatively affect a resident if the facility is not kept in good repair because of the risk of injuries. DON stated it was her expectation that the facility be kept clean. DON stated she was unsure of how often the facility handrails are cleaned. DON stated HK are responsible for cleaning the facility handrails. DON stated it was her expectation that if the mechanical lift looks like it needs to be cleaned then it would be cleaned. DON stated she was unsure who was responsible for cleaning the mechanical lift or if there was a scheduled cleaning rotation. DON stated if the lift is soiled then the CNAs use sanitizer wipes to clean it. DON stated she did not believe if the mechanical lift was not cleaned that it could negatively affect the residents since the sling is the part of the lift that touches the resident and that each resident has their own slings that are laundered by facility staff. DON stated that it was her expectation regarding shower rooms that after each resident shower the CNA gathers all products used and picks up after themselves. [NAME] stated that housekeeping is responsible for cleaning the walls and floor of the shower rooms. DON stated she was unsure of the cleaning rotation with housekeeping. DON stated it could negatively affect residents if the shower rooms are not kept clean because of germs. Record review of maintenance log binder reflected the fire door magnet, the smoking door jagged metal piece, the loading dock door jagged metal trim, and the smoking door top door mechanism cover had not been recorded in the maintenance binder as items needing repair or replacement. Record review of facility's policy, dated 02/01/2017, titled Maintenance Service reflected Policy: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Procedure: 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. Maintaining the building in good repair and free from hazards. f. Establishing priorities in providing repair service. 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. The Maintenance Director is responsible for maintaining the following records/ reports. a. Inspection of building; Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's kitchen reviewed for dietary services. The facility failed to ensure food was labeled and dated correctly in the refrigerator, freezer, and pantry on 04/26/26. This failure could place residents at risk of foodborne illnesses. Observation of the kitchen on 04/26/26 at 9:18 AM revealed the following:There were 2 opened packages of French fries in the freezer that did not have any dates on them.There was a container with Jello (a sweet gelatin-based dessert made from animal derived gelatin) that had a preparation date of 04/01/26 and a used by date of 04/02/26 in the refrigerator that had not been thrown away.There was an opened loaf of bread in the pantry that had a manufacturer's date of 06/24/26 on it but did not have a delivery date or an open date on it.There were six loaves of bread in the pantry with a manufacturer's date 06/24/26 on them, but they did not have a delivery date on them. Observation of the kitchen on 04/26/26 at 9:27 AM revealed the following verbiage was posted on the front of the refrigerator door: Any food that is 3 days past date on container must be thrown away. Interview with the DM on 04/26/26 at 10:02 AM revealed all kitchen staff were responsible for putting dates on food packages when they were delivered. The DM stated there should be a delivery date and an open date or prep (to prepare or cook food ahead of time) date on all food. She stated the manufacturer's expiration date was the disposal date for the food in the pantry and package foods in the refrigerator and freezer. The DM said the prepped food in the refrigerator had a prep date and a used by date and the food items were disposed of 3 days after the used by date. She advised the opened containers in the refrigerator of food that were not prepped had an open date and the manufacturer's date was the disposal date. The DM did not know why food items were not dated correctly as she stated staff knew what dates to use. The DM said she would review the food storage policy with the kitchen staff as soon as possible. Interview with CK G on 04/27/26 at 11:49 AM revealed she was unaware food items were not dated correctly. CK G said all kitchen staff were responsible for dating food when it was delivered to the facility. She stated the dates on the food depended on the food item. CK G stated there should be a delivery date and an open date or prep date on all food items. She stated the manufacturer's expiration date was the disposal date for the food in the pantry and for packaged food or food that came in a container in the refrigerator and freezer. CK G said the prepped food in the refrigerator had a prep date and a used by date. She stated they threw away food 3 days after the used by date. She said the opened containers in the refrigerator of food (that they did not have to prep) had an open date and the manufacturer's date was the throw away date. Telephone interview on 04/28/26 at 12:48 PM with the RD revealed all food items must have a delivery date on them. She stated dry food storage and freezer items should have a check-in date and they used the manufacturer's expiration date as the disposal date. She stated all refrigerator food items should have a delivery date, an open date, and a used by date for all prepped food. She stated prepped food must be thrown away 3 days after the used by date. The RD said food in the refrigerator that was not prepped was disposed by the manufacturer's date. She stated all kitchen staff were responsible for ensuring all food items were dated correctly to prevent foodborne illnesses. Interview with the ADM on 04/28/26 at 4:03 PM revealed she was unaware food was not dated and stored correctly. She said all kitchen staff were responsible for putting dates on food packages when they were delivered. The ADM advised the food storage policy was in place to prevent food-borne illnesses. The ADM concluded that a follow-up with kitchen staff to review the food storage policy would be completed as soon as possible. Record review on 04/27/26 of the food storage policy (effective date 01/2018 and revised 02/2026) revealed the following:Policy: Food should be stored in a safe and sanitary method to prevent contamination and food-borne illness. All food should be stored according to state, local, and federal regulations. ProcedureDry storage roomb. Bulk items that have been opened should be stored in covered containers or sealed bags and should be labeled and dated. 2. Refrigerators c. Refrigerated food should be dated, labeled, and sealed. d. Leftovers should be used within 3 days. Discard items after 3 days.3. Freezers d. Items should be sealed, labeled, and dated.

Based on observation, interview and record review the facility failed ensure the resident had a right to personal privacy and confidentiality of his or her personal and medical records for 15 of 20 residents (Residents #12, #54,#13, #10, #6, #49, #27,#47, #30, #33, #69, #20, #21, #45 and #29) reviewed for privacy and confidentiality. 1. The facility failed to ensure Residents #47, #30, #33, #69, #20, #21, #45 and #29 vital sign information was not exposed and left on top of MA F's medication cart unattended on 04/26/26. 2. The facility failed to ensure resident/responsible party education, for Out on Pass signed documents, which documented resident names and responsible party name and signatures were not exposed on the receptionist front window counter for Residents #13, #!2 and #54 on 4/26/26. 3. The facility failed to ensure resident personal information which included names and prescribed medications was not exposed on a counter next to the copy machine in public hallways for Residents #12, #6, #49, #27 and #10 on 4/26/26. 4. The facility failed to ensure ambulance transport certification documents, for Resident # 10, which documented the resident's personal information, was not exposed on the counter next to the copy machine in the public hallway on 4/26/26. These failures could place residents at risk of not having their personal privacy maintained during medication administration and their medical information exposed to unauthorized individuals.1. Record review of Resident #47's admission Record, dated 04/28/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with Parkinson's disease (a chronic degenerative disorder of the central nervous system that affects both the motor system and non-motor systems), diabetes (a group of diseases that result in too much sugar in the blood), chronic obstructive pulmonary disease (a lung disease characterized by chronic respiratory symptoms and airflow limitation), and bipolar disorder (a chronic mental health condition characterized by extreme mood swings, alternating between intense highs (mania or hypomania) and severe lows (depression). Record review of Resident #47's Quarterly MDS Assessment, dated 04/09/26, reflected the resident had a BIMS score of 15, which indicated the resident was cognitively intact. 2. Record review of Resident #30's admission Record, dated 04/28/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with multiple sclerosis (a chronic autoimmune disease where the immune system attacks the protective myelin sheath covering nerves in the brain and spinal cord), chronic kidney disease (long standing disease of the kidneys leading to renal failure), atherosclerotic heart disease of native coronary artery (coronary artery disease) (heart disease involving the reduction of blood flow to the cardiac muscle due to a buildup of atheromatous plaque in the arteries of the heart), and hyperlipidemia (abnormally high levels of any or all lipids or lipoproteins in the blood). Record review of Resident #30's Quarterly MDS Assessment, dated 04/10/26, reflected the resident had a BIMS score of 15, which indicated the resident was cognitively intact. 3. Record review of Resident #33's admission Record, dated 04/28/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with cerebrovascular disease (a general term for conditions that affect the blood vessels in the brain and spinal cord, which can lead to serious complication), chronic obstructive pulmonary disease (a lung disease characterized by chronic respiratory symptoms and airflow limitation), diabetes (a group of diseases that result in too much sugar in the blood), and benign prostatic hyperplasia (a common noncancerous enlargement of the prostate gland in men, typically occurring with aging, which causes lower urinary tract symptoms like weak stream, frequency, and nocturia). Record review of Resident #33's Quarterly MDS Assessment, dated 03/05/26, reflected the resident had a BIMS score of 15, which indicated the resident was cognitively intact. 4. Record review of Resident #69's admission Record, dated 04/28/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a lung disease characterized by chronic respiratory symptoms and airflow limitation), dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), and psychosis (a disconnection from reality characterized by symptoms like hallucinations (seeing/hearing things) and delusions (false beliefs). Record review of Resident #69's Quarterly MDS Assessment, dated 02/20/26, reflected the resident had a BIMS score of 15, which indicated the resident was cognitively intact. 5. Record review of Resident #20's admission Record, dated 04/28/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and chronic pain syndrome (a long-term condition lasting 3-6+ months, extending beyond initial injury to include profound emotional, physical, and functional impairment, such as depression, anxiety, and fatigue). Record review of Resident #20's Quarterly MDS Assessment, dated 04/26/26, reflected the resident had a BIMS score of 12, which indicated the resident was moderately cognitively impaired. 6. Record review of Resident #21's admission Record, dated 04/28/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (COPD) (a lung disease characterized by chronic respiratory symptoms and airflow limitation), diabetes (a group of diseases that result in too much sugar in the blood), dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), and dysphagia (difficulty in swallowing). Record review of Resident #21's Quarterly MDS Assessment, dated 04/14/26, reflected the resident had a BIMS score of 03, which indicated the resident was severely cognitively impaired. 7. Record review of Resident #45's admission Record, dated 04/28/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with atherosclerotic heart disease of native coronary artery (coronary artery disease) (heart disease involving the reduction of blood flow to the cardiac muscle due to a buildup of atheromatous plaque in the arteries of the heart), dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), bipolar disorder (a chronic mental health condition characterized by extreme mood swings, alternating between intense highs (mania or hypomania) and severe lows (depression), and insomnia (a common sleep disorder marked by persistent difficulty falling asleep, staying asleep, or getting quality rest, leading to daytime fatigue, irritability, poor concentration, and mood issues, and it can be short-term (acute, from stress) or long-term (chronic, lasting months). Record review of Resident #45's Quarterly MDS Assessment, dated 03/25/26, reflected the resident had a BIMS score of 03, which indicated the resident was severely cognitively impaired. 8. Record review of Resident #29's admission Record, dated 04/28/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with bipolar disorder (a chronic mental health condition characterized by extreme mood swings, alternating between intense highs (mania or hypomania) and severe lows (depression), anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and obsessive-compulsive disorder (a chronic mental health condition characterized by uncontrollable, recurring thoughts (obsessions) and/or repetitive behaviors ([compulsions]) that a person feels driven to perform to reduce anxiety). Record review of Resident #29's Quarterly MDS Assessment, dated 03/26/26, reflected the resident had a BIMS score of 12, which indicated the resident was moderately cognitively impaired. 9. Record review of Resident #13's admission Record, dated 04/28/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with a re-admission date of 2/1/23. The resident was diagnosed with seizures, mild cognitive impairment, localized edema (swelling), anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood), hypothyroidism (underactive thyroid gland), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), personality disorder (a mental health condition characterized by long-term, rigid, and unhealthy patterns of thinking, functioning, and behaving that differ significantly from cultural expectations), anxiety disorder (a condition marked by intense, excessive, and persistent worry and fear about everyday situations, heart failure, unspecified convulsions, hypokalemia (low blood potassium levels), acute kidney failure, lack of coordination, hypertension (high blood pressure), muscle weakness, morbid obesity, abnormalities of gait and mobility, cognitive communication deficit (a breakdown in communication caused by underlying cognitive impairment rather than a language or speech defect) and acute respiratory distress. Record review of Resident #13's Quarterly MDS Assessment, dated 4/3/26, reflected the resident had a BIMS score of 15, which indicated intact cognition. 10. Record review of Resident #12's admission Record, dated 4/28/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with a re-admission date of 2/23/26. The resident was diagnosed with type 2 diabetes (condition where the body resists insulin or fails to produce enough insulin causing high blood sugar levels), hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side (weakness or paralysis of right side following stroke), atherosclerotic heart disease (a condition where plaque builds up in the arteries hardening them), aphasia following cerebral infarction (a language disorder that impairs the ability to speak after a stroke), blindness in one eye low vision in other eye, peripheral vascular disease (circulation disorder involving narrowing or blockage of blood vessels outside the heart), chronic kidney disease stage 2, muscle wasting and atrophy, dementia (a progressive decline in cognitive function including memory, thinking , and reasoning severe enough to interfere with daily life), gangrene, osteomyelitis (a severe inflammation or infection of the bone and bone marrow), anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood), cognitive communication deficit (a breakdown in communication caused by underlying cognitive impairment rather than a language or speech defect), protein-calorie malnutrition, methicillin resistant staphylococcus aureus infection (a type of bacteria responsible for difficult to treat infections due to its resistance to common antibiotics), and amputation of right great toes and left toes. Record review of Resident #12's Quarterly MDS Assessment, dated 4/16/26, reflected the resident had a BIMS score of 9, which indicated moderate cognitive impairment. 11. Record review of Resident #54's admission Record, dated 4/28/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with a re-admission date of 11/3/25. The resident was diagnosed with congestive heart failure (a chronic progressive condition where the heart muscle is too weak or stiff to pump blood efficiently), type 2 diabetes (condition where the body resists insulin or fails to produce enough insulin causing high blood sugar levels), bipolar disorder (a chronic mental health condition characterized by extreme mood swings alternating between intense highs and severe lows), insomnia (a common sleep disorder characterized by persistent difficulty falling asleep or staying asleep), anxiety (intense, excessive, and persistent worry and fear about everyday situations), schizoaffective disorder bipolar type (a chronic mental health condition combining schizophrenia symptoms of hallucinations and delusions with manic episodes extreme highs and often depression), viral hepatitis C (a contagious liver disease caused by the hepatitis C virus), osteoporosis (bone weakness ), chronic respiratory failure with hypoxia (a long-term gradual and progressive condition where the lungs cannot adequately transfer oxygen to the blood resulting in persistently low blood oxygen levels), Parkinson's disease (a progressive neurodegenerative movement disorder caused by loss of dopamine producing neurons in the brain), dementia (a progressive decline in cognitive function including memory, thinking , and reasoning severe enough to interfere with daily life), major depressive disorder (a serious mental health condition characterized by persistent intense sadness or a loss of interest in activities for a least 2 weeks), chronic obstructive pulmonary disease (a progressive ling disease that causes damaged inflamed airways making it hard to breath), morbid obesity, left leg above knee amputation, hypokalemia (low blood potassium levels), resistance to multiple antibiotics, and cognitive communication deficit (a breakdown in communication caused by underlying cognitive impairment rather than a language or speech defect). Record review of Resident #54's Quarterly MDS Assessment, dated 4/14/26, reflected the resident had a BIMS score of 15, which indicated intact cognition. 12. Record review of Resident #6's admission Record, dated 4/28/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE] with a re-admission on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a progressive ling disease that causes damaged inflamed airways making it hard to breath), schizophrenia (a serious brain disorder that disrupts how a person thinks, feels, and acts often causing difficulty distinguishing reality from imagination), anxiety disorder, hypertension (high blood pressure), gout (a common painful form of inflammatory arthritis characterized by sudden severe attacks of joint pain swelling and tenderness), insomnia (a common sleep disorder characterized by persistent difficulty falling asleep or staying asleep), anorexia (an eating disorder and serious mental health condition characterized by a person trying to keep their weight as low as possible through extreme exercise not eating and vomiting), depression, edema (swelling), osteoarthritis (a common form of arthritis a chronic degenerative joint disease), anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood), and muscle weakness. Record review of Resident #6's Comprehensive MDS Assessment, dated 4/2/26, reflected the resident had a BIMS score of 15, which indicated intact cognition. 13. Record review of Resident #49's admission Record, dated 4/28/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), schizoaffective disorder bipolar type (a chronic mental health condition combining schizophrenia symptoms of hallucinations and delusions with manic episodes extreme highs and often depression), anxiety disorder, insomnia (a common sleep disorder characterized by persistent difficulty falling asleep or staying asleep), contracture of right and left hand, muscle weakness, lack of coordination, bipolar disorder (a chronic mental health condition characterized by extreme mood swings alternating between intense highs and severe lows), schizophrenia (a serious brain disorder that disrupts how a person thinks, feels, and acts often causing difficulty distinguishing reality from imagination), hypokalemia (low blood potassium levels), heart failure, major depressive disorder (a serious mental health condition characterized by persistent intense sadness or a loss of interest in activities for a least 2 weeks), unspecified psychosis, and gastroesophageal reflux disease (a chronic digestive condition where stomach acid frequently flows back into the esophagus). Record review of Resident #49's Quarterly MDS Assessment, dated 3/4/26, reflected the resident had a BIMS score of 3, which indicated severe cognitive impairment. 14. Record review of Resident #27's admission Record, dated 4/28/26, reflected a 66 -year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. The resident was diagnosed with schizoaffective disorder bipolar type (a chronic mental health condition combining schizophrenia symptoms of hallucinations and delusions with manic episodes extreme highs and often depression), anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood), muscle weakness, major depressive disorder (a serious mental health condition characterized by persistent intense sadness or a loss of interest in activities for a least 2 weeks), lack of coordination, acute kidney failure, anxiety disorder, cognitive communication deficit (a breakdown in communication caused by underlying cognitive impairment rather than a language or speech defect), hyperlipidemia (elevated fat particles in the blood), tachycardia (a heart rhythm disorder), and abnormalities of gait and mobility. Record review of Resident #27's Quarterly MDS Assessment, dated 4/17/26, reflected the resident had a BIMS score of 3, which indicated severe cognitive impairment. 15. Record review of Resident #10's admission Record, dated 4/28/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. The resident was diagnosed with persistent vegetative state (a chronic, severe disorder of consciousness where a patient with severe brain damage appears to be awake but lacks awareness of their surroundings and has no cognitive function), chronic respiratory failure with hypoxia (a long-term gradual and progressive condition where the lungs cannot adequately transfer oxygen to the blood resulting in persistently low blood oxygen levels), congestive heart failure (a chronic progressive condition where the heart muscle is too weak or stiff to pump blood efficiently), tracheostomy status (an artificial surgical opening in the neck used for long-term breathing support), hypertension (high blood pressure), dysphagia (swallowing difficulty), aphasia (a language disorder that impairs the ability to speak), muscle wasting and atrophy, morbid obesity, atherosclerotic heart disease, unspecified convulsions, anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood), GERD (a chronic digestive condition where stomach acid frequently flows back into the esophagus), cardiomegaly, cataract, contractures to bilateral upper extremities. Record review of Resident #10's Quarterly MDS Assessment, dated 3/7/26, reflected the resident had a BIMS score that was not documented. In an observation on 04/26/26 at 9:36 AM, during a facility walk through, revealed on the receptionist front window counter 3 resident/responsible party education for Out on Pass signed documents which contained resident names and resident responsible party names and signatures laid exposed on the front counter for anyone passing by to see. In an observation on 04/26/26 at 10:11 AM, during a facility walk through, revealed on the counter next to the copy machine in a public hallway a list of record of disposal for medications for 5 residents (Residents #12, #6, #49, #27 and #10 which contained resident names and resident medication names laying exposed on the counter in the public hallway for anyone passing by to see. In an observation on 04/26/26 at 10:15 AM, during a facility walk through, revealed on the counter next to the copy machine in a public hallway were ambulance transport certification documents for 1 resident (Resident #10) which contained the resident name, date of birth , sex, ethnicity, address, primary care provider, race, phone number, emergency contacts name and phone numbers, insurance provider information, hospital account number, advance directive status, and medical record number laid exposed on the counter next to the copy machine in the public hallway for anyone passing by to see. In an observation on 04/26/26 at 11:37 AM, during a medication administration observation, revealed a sheet of white paper which contained resident's #47, #30, #33, #69, #20, #21, #45, #29's names and vital sign information laid exposed for others to see on top of a medication cart. In an interview on 04/26/26 at 11:43 AM, RN F stated he meant to put the paper that included residents' name and vital signs in his pocket and he usually kept any information which contained resident information put away or in his pocket. He stated he was trained on HIPPA and if resident information was left out in the open and exposed, it could have violated the residents' rights and been an invasion of residents' privacy. In an interview on 04/26/26 at 2:45 PM, CNA D stated she was in-serviced on privacy and resident rights. She stated anything containing resident information should have been put away and should not have been out for anyone to see. She stated it was a HIPPA violation for resident information to be out in the open for the public to see. She stated if resident information was left exposed, it could have been an invasion of the residents' privacy, and it would have been against their resident rights. In an interview on 04/27/26 at 11:34 AM, CNA E stated was in-serviced regularly on privacy and resident rights. She stated anything containing resident information should have been put away and not been out for anyone to see. She stated it was a HIPPA violation for resident information to be left out in the open for the public to see. She stated if resident information was left exposed, it could have caused a HIPPA violation and would have caused the resident to have their privacy invaded. In an interview on 04/27/26 at 11:56 AM, LVN C stated she was in-serviced regularly on privacy and resident rights. She stated anything containing resident information should have been put away and not been left out for anyone to see. She stated it was a HIPPA violation for resident information to be left out in the open for the public to see. She stated if resident information was left exposed, it could have caused the resident to have anxiety, or it would have been an invasion of their privacy. In an interview on 04/27/26 at 12:25 PM, RN A stated she worked in the facility for about 2 years. She stated she was in-serviced regularly on privacy and resident rights. She stated anything containing resident information should have been put away and not been left out for anyone to see. She stated it was a HIPPA violation for resident information to be out in the open for the public to see. She stated if resident information was left exposed, it would be a HIPPA violation and would have been an invasion of their privacy and would be against the residents' rights. In an interview on 04/27/26 at 1:10 PM, the ADM stated staff were in-serviced on privacy and resident rights. She stated anything containing resident information should have been put away and not been left out for anyone to see. She stated it was a HIPPA violation for resident information to be left out in the open for the public to see. She stated if resident information was left exposed, it could have caused the resident financial issues and would have been an invasion of their privacy and resident rights. In an interview on 04/28/26 at 12:32 PM, the DON stated she had in-serviced staff regularly on privacy and resident rights. She stated anything containing resident information should have been put away and not been left out for anyone to see. She stated it was a HIPPA violation for resident information to be left out in the open for the public to see. She stated if staff were on a nursing cart and resident information was in front of the staff member while the staff was present that would be ok, but the staff member should not have walked away and left any information exposed. She stated if resident information was left exposed, it could have caused the resident an invasion of their privacy and been against their resident rights. Record review of the facility's policy, dated 2001 and revised October 2017, titled Confidentiality of Information and Personal Privacy reflected Policy Statement: Our facility will protect and safeguard resident confidentiality and personal privacy. Policy Interpretation and Implementation: The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. 2. The facility will strive to protect the resident's privacy regarding his or her: b. medical treatment; c. written and telephone communications; d. personal care.

Based on interview and record review the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 6 residents (Resident #6) reviewed for PASARR assessments. The facility failed to ensure Resident #6 was referred to the mental health authority after receiving a new diagnosis of schizoaffective disorder. This failure could place residents at risk for a diminished quality of life and not receiving needed care and services in accordance with individually assessed needs.Findings include: Record review of Resident #6's admission Record, dated 04/28/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident had diagnoses which included chronic obstructive pulmonary disease (a lung disease characterized by chronic respiratory symptoms and airflow limitation), anxiety (intense, excessive, and persistent worry and fear about everyday situations), schizophrenia (a severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking), and osteoarthritis - (a degenerative joint disease that causes the cartilage and bone in a joint to break down over time). Resident #6's admission record reflected Resident #6 had a diagnosis of schizophrenia with an onset date of 04/12/25. Record review of Resident #6's Significant Change MDS Assessment, dated 04/04/26, reflected the resident had a BIMS score of 15, which indicated the resident was cognitively intact. Resident #6 required set up or clean up assistance for eating and substantial/maximal assistance with toileting, showering, and personal hygiene. Record review of Resident #6's care plan, dated 05/28/25, reflected Focus: [Resident #6] was on antipsychotic medication r/t: Schizophrenia. Goal: Resident will remain free from adverse reactions related to antipsychotic medication therapy. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Monitor/record occurrence of targeted behavior and document per protocol. In an interview on 04/28/26 at 12:23 PM, LVN B stated she was responsible for PASSAR's in the facility. She stated she had been in-serviced on PASSAR evaluations and completion and the PASARR process. She stated when a resident admitted , their PASARR should have already been completed. She stated if the PASSAR was not completed she would have immediately notified the sending facility and if she was not able to get a hold of them, she would have completed the PASSAR. She stated if a resident received a new psychological/IDD diagnosis after their PASSAR was completed, she would have filled out a 1012 form. She stated if the resident's primary diagnosis was dementia, she would have filled out the first form and stopped there, but if not, she would have went on to the next page and completed the PASSAR assessment. She stated then someone from the local authority would have come and done the residents PASSAR evaluation. She stated she was not aware Resident #6 received a new diagnosis of schizophrenia after she had a negative PASSAR completed. She stated a new PASSAR screening should have been completed when Resident #6 received the new diagnosis for schizophrenia. She stated if a residents PASSAR had not been done or the process had not been completed correctly, it could have caused a resident to miss their assessment to determine if they were eligible for additional benefits through PASSAR services. In an interview on 04/28/26 at 12:32 PM, the DON stated LVN B was responsible for PASSAR assessments in the facility, and she had been trained on the PASSAR process and completion. She stated the corporate office made the decisions on who all admitted to the facility. She stated if a resident received a new psychological/IDD diagnosis after their PASSAR was completed, LVN B would have needed to do a new PASSAR screening. She stated she was not aware Resident #6 received a new diagnosis of schizophrenia after her initial negative PASSAR was completed. She stated a new PASSAR screening should have been completed when Resident #6 received the diagnosis for schizophrenia. She stated if a resident's PASSAR was not done or the process was not completed correctly, it could have caused the resident to miss out on services that they could have benefited from. In an interview on 04/27/26 at 1:10 PM, the ADM stated LVN B was responsible for PASSAR assessments in the facility, and she had been trained on the PASSAR process and completion. She stated if a resident received a new psychological/IDD diagnosis after their PASSAR was completed, a form should have been completed to reassess residents PASSAR status. She stated she was not aware Resident #6 received a new diagnosis of schizophrenia after her initial negative PASSAR was completed. She stated a new PASSAR screening should have been completed when Resident #6 received the diagnosis for schizophrenia. She stated if a residents PASSAR assessment was not done or the process was not completed correctly, it could have caused the resident to have a lack of services that they could have been entitled to receive. Record review of the facility policy, dated 11/2023, and titled Resident Assessment reflected Policy: The purpose of this policy is to ensure PASRRs are being obtained and completed timely and accurately. PROCEDURE: 6. Follow Texas PASRR Policy for all mandatory meetings and care coordination including any changes that may require a change in resident's PASRR status. Record review of the Texas Health and Human Services' (PASRR) for Nursing Facilities online When a nursing facility (NF) resident with a negative PASRR (Level I) receives a new, confirmed diagnosis of an Intellectual or Developmental Disability (IDD), it is considered a significant change in condition requiring a Resident Review (RR). The facility must notify the Local Intellectual and Developmental Disability Authority (LIDDA) to conduct a new evaluation within seven calendar days.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of six residents reviewed for infection control. The facility failed to ensure staff practiced hand hygiene when entering and exiting Resident #1's room, who required enhanced barrier precautions. The failure put residents at risk for infection, hospitalization, and decreased quality of life.Findings included: Record review on 04/07/2026 at 2:35 PM Resident #1's electronic medical record revealed that Resident #1 was admitted on [DATE]. Resident #1 had a history of bipolar disorder (Mood swing), epilepsy (Seizure), GERD (Gastro Esophageal Reflux Disease - acid or food coming back up) Without Esophagitis, and adjustment disorder with anxiety. Full Code. BIMS score was at 12 (Mild cognitive impairment). During an interview and observation on 04/07/2026 at 11:17 a.m., the surveyor notified ADM that Resident #1 wanted to talk to the facility ADM Before entering the room of Resident #1, the surveyor noticed EBP signage posted on the door. Observation reflected Resident #1 was assisted back from therapy. Observation reveal that the therapy personnel did not perform hand hygiene during entry or exit from Resident #1's room. Observation further revealed that ADM went directly into Resident #1's room without performing hand hygiene. Before entering the room, the surveyor told ADM that the surveyor would perform hand hygiene because the EBP signage required it. ADM then performed hand hygiene and returned to Resident #1's room During an interview on 04/08/2026 at 11:27 a.m., LVN-A stated she was in-serviced regularly on abuse, neglect, misappropriation, hand washing, hand hygiene, infection control, and resident rights. LVN-A stated that a negative outcome of not following the EBP signage and not promoting hand hygiene was the spread of infection to the residents, herself, or others. LVN-A stated EBP signage was placed at the resident's door to prevent infection. She statednurses were responsible for placing the EBP sign on the resident's door. During an interview on 04/08/2026 at 11:35 a.m., CNA-B stated she was in-serviced regularly on abuse, neglect, misappropriation, hand washing, hand hygiene, infection control, and resident rights. CNA-B stated that the negative outcome of not following EBP signage could include the spread of infection to residents, herself, or others. During an interview on 04/08/2026 at 11:50 a.m., THP-C stated he was in-serviced regularly on abuse, neglect, misappropriation, hand washing, hand hygiene, and infection control. THP-C stated a negative outcome of not following the EBP signage could be cross-contamination and the spread of infection. THP-C stated that Room Ready personnel (the person who makes the room ready for the new resident) and DON approved the EBH sign on the resident's door. During an interview on 04/08/2026 at 12:00 p.m., DON stated she was in-serviced regularly on abuse, neglect, misappropriation, hand washing, hand hygiene, infection control, and resident rights. DON stated a negative outcome of not following the posted EBP signage on the door was the spread of infection to the residents, herself, or others. DON stated that room-ready personnel , central supply personnel, DON, and nurses were responsible for placing the EBP sign on the resident's door. DON stated that DON, ADON, ADM, and the wound care nurse ensured the EBP signage was followed through by all the staff members before entering and exiting residents with the signage of EBP. The DON stated that frequent monitoring and in-services, along with partner rounds each partner is following their duties properly), could be conducted to ensure compliance with EBH protocols. During an interview on 04/08/2026 at 12:10 p.m., ADM stated she was in-serviced regularly on abuse, neglect, misappropriation, hand washing, hand hygiene, infection control, and resident rights. ADM stated a negative outcome of not following the EBP signage and not promoting hand hygiene was the spread of infection to the residents, herself, or others. The ADM stated that room-ready personnel, central supply personnel, the DON, and nurses were responsible for placing the EBH sign on the resident's door. ADM stated DON, ADON, and AD, and the wound care nurse (A nurse who specialized in wound care) made sure the signs were followed through. ADM stated that frequent monitoring and in-services, along with partner rounds, could be conducted to follow through on EBH protocols. ADM stated that, after talking to DON, the facility realized that no EBP signed was required for Resident #1 because Resident #1 was not in isolation at that time. Record review on in-service and education record, dated 4/7/26, topic EBP-Hand sanitizing in-service had been provided on 4/7/26. The EBH sign noted: Enhanced barrier precautions everyone must: Clean their hands, including before entering, and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activitiesDressing, Bathing/showering, Transferring, Changing linens, Providing hygiene, Changing briefs or assisting with toileting. Device care or use: Central line, urinary catheter, feeding tube, tracheostomy.Wound care: Any skin opening requiring a dressing.Do not wear the same gown and gloves for the care of more than one person. Record review of the facility's policy titled, Infection Control , dated of 4/1/2024, stated that Enhanced Barrier Precautions (EBP) are a CDC guidance to reduce the transmission of multi-drug resistant organisms (MDRO) in health care settings, including nursing homes. Place signage on resident's closet door, maintain PPE in residents' room, and assure all team members are aware of resident status and need for EBP during high contact care.

Based on observations, interviews, and record review the facility failed to ensure residents received adequate supervision, to the extent possible for 1 of 8 residents (Resident #1) reviewed for safety.The facility failed to ensure Resident #1 was provided adequate supervision on 02/08/2026 when Resident #1 pushed open a facility exit door, activating both the door alarm and Resident #1's wander guard alarm, and exited the facility traveling approximately 500 ft, crossing a street, and falling (no injuries). The facility was notified by a passerby driving a car of resident's elopement.The noncompliance was identified as Past Noncompliance. The Immediate Jeopardy (IJ) began on 02/08/2026 and ended on 02/09/2026. The facility had corrected the noncompliance before the survey began.These failures could place residents at risk for avoidable accidents, injuries, and possible death.Findings included: Record review of Resident #1's face sheet, dated 02/26/2026, revealed a ninety-two-year-old male who was admitted to the facility on [DATE]. His admitting diagnoses included major depressive disorder (a serious mental health condition characterized by persistent, intense feelings of sadness, worthlessness, and loss of interest in activities lasting at least two weeks), restlessness and agitation, and impulsiveness. Record review of Resident #1's care plan revealed a focus dated 11/25/2025 Resident #1 was an elopement risk/wanderer and was at risk for possible injury related to impaired safety awareness and diagnoses of dementia (a progressive, irreversible syndrome characterized by a decline in memory, thinking, behavior, and daily function due to nerve cell damage) with interventions dated 11/25/2025 distract Resident #1 from wandering by offering pleasant diversions, structured activities, food, conversation, television or books, provide structured activities: toileting, walking inside and outside, reorientation strategies, including signs, pictures and memory boxes and wander guard (a small discreet wearable device), worn as a bracelet to prevent at-risk residents from wandering, bracelet will alert staff if and when resident attempted to exit doors of facility) and staff to monitor daily. Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) dated 11/25/2025 Quarterly Assessment Section C - Cognitive Patterns revealed a score of 6 indicating severe cognitive issues and Section E- Behavior Wandering - Presence and Frequency has the resident wandered, revealed behavior not exhibited. Observation on 02/27/2026 at 3:55 PM of facility non-audio video dated 02/08/2026 revealed at 10:58:30 AM Resident #1 was standing directly in front of an exit door with his walker in front of him. No other person observed in the video. Video reflected Resident #1 pushed on the keypad next to the exit door and pushed on the bar of the exit door that was a security barrier that kept the door locked from the outside and, temporarily for 15 seconds, from the inside. At 10:58:57 AM Resident #1 opened the exit door and walked out the door. At 10:59:08 AM the exit door closed. At 11:01:19 AM the FT walked to the exit door, entered the alarm code on keypad turning off the alarm, turned away and walked away from the exit door. During an interview on 02/27/2026 at 4:15 PM with the Administrator she said Resident #1 eloped out a back side door of the facility and traveled down the concrete ramp exit. At the bottom of the ramp Resident #1 turned right crossing a grassy yard. Resident #1 crossed a residential street with a speed limit of 30 mph. After crossing the street Resident #1 fell. Resident #1 traveled approximately 500 ft. from the exit door to where he fell. The Administrator estimated Resident #1 was gone from the facility for about 30 minutes. Record review of www.wunderground.com reflected the weather on 02/08/2026 was cool, dry, breezy with an average temperature of 61.81 degrees Fahrenheit. Record review of HHS Facility Provider Investigative Report dated 02/08/2026 reflected Resident #1 was observed outside the facility in adjacent parking lot on the ground. Resident was assisted back to the facility by facility staff. Resident had no visible signs of injury and did not exhibit any signs of emotional stress. Facility video recording showed Resident #1 going to exit door and pushing on crash bar (a safety mechanisms installed on commercial doors to provide fast, easy, and secure egress during emergencies) until lock was released and then exited the building. Staff members responded to the door alarm to turn it off without following door alarm process. Record review of Resident #1's admission Elopement assessment dated [DATE] reflected Resident #1 was a high risk for elopement. During an interview on 02/27/2026 at 3:43 PM with the Administrator she said there were seven people working that day and anyone in the facility could turn the door alarm off, but all staff knew that they needed to open the door and look outside for a resident before they turned the alarm off and walked away. The Administrator said Resident #1 went to the door and pushed the door until it was released and the FT did not open the door to look out and check if a resident was outside. The Administrator said Resident #1 made it out the door, down a ramp into the facility parking lot and across the street and he fell. Two people in a car passing by saw Resident #1 on the ground. One of the passersby came to the laundry room and knocked on the door. The laundry person went directly to get RN B and did not go out to see Resident #1 and had no additional involvement. LVN A assessed Resident #1 and found no injuries. Resident #1 was placed on 1:1 until he was discharged to another skilled nursing facility with a secure unit. The Administrator said the facility failed to follow the elopement policy. The Administrator said if the elopement policy were not followed a resident could be seriously harmed if they eloped from the facility. During an interview on 02/27/2026 at 4:24 PM with RN B he said he was the weekend supervisor and worked on 02/08/2026 when Resident #1 eloped. RN B said someone (he did not remember the name) from the laundry room got him and said a guy outside knocked on the laundry door and said that one of their residents was across the street. RN B said the by passer-by and his wife had walked Resident #1 back to the facility (he did not get the by passers names). RN B said when Resident #1 came back into the facility, Resident #1's wander guard sounded its alarm. RN B said the Administrator came to the facility and investigated how the incident happened. RN B thought it was a problem with the door latch. RN B said that Resident #1 was not hurt and Resident #1's assessment by LVN A showed no bruises or cuts. RN B told them passersby said Resident #1 crossed the street, had fallen, and was in the dirt. The passersby were in a car driving by when they saw Resident #1 waiving. RN B said Resident #1's family was called and Resident #1 was placed on 1:1 immediately. During an interview on 02/27/2026 at 4:37 PM LVN A said she assessed Resident #1 when he returned to the facility after he eloped on 02/08/2026. LVN A said Resident #1 did not have any injuries and she believed that Resident #1 was gone from the facility about 30 minutes. LVN A said Resident #1 constantly wanted to go home and that was the reason he had a wander guard. LVN A said Resident #1 had no previous elopements and he was placed on 1:1 (constant monitoring arrangement where one staff member was assigned to a single resident) for the last 3 or 4 days he was at the facility then Resident #1 was discharged to a facility with a secured unit. LVN A said if a resident eloped from the facility the resident could fall and break something or they could get run over by a car or they could get sick or die. Attempted interview by phone on 02/27/2026 at 4:42 pm with the FT. A voice mail and a text message were sent to the FT. No response received from the FT. During an interview on 02/27/2026 at 6:18 PM the ADON said if a door alarm goes off or a wander guard alarm sounds you did not just turn the alarm off. She said you should look outside and make sure no resident got out of the facility and make sure residents are accounted for. She said if a resident eloped from the facility, they could get hurt or even die. During an interview on 03/02/2026 at 1:30 PM RN A said Resident #1 was a wanderer, but he did not ask to leave or push on doors. She said except for wandering, Resident #1 did not have exit seeking behaviors prior to his elopement. During an interview on 03/02/2026 at 2:07 PM with the HOH he said before Resident #1's elopement his housekeeping staff including the FT were trained that if a facility alarm sounded, they were to look out the door and see if a resident went outside and then turn the alarm off. The HOH said if a resident left the facility a resident could get lost or get into an accident. He said a lot of things could happen if a resident eloped. He said that prior to this, he had not seen Resident #1 try to leave the facility. During an interview on 03/02/2026 at 2:20 PM with CNA A she said Resident #1 did not have exit seeking behaviors prior to the elopement. She said that if someone eloped from the facility they could get hit by a car, fall down or worse pass away. She said she received training about the alarms when she began working at the facility. CNA A said she was trained that if a door alarm went off, you needed to look outside and see if a resident went outside before the alarm was turned off. She said if someone went outside, you needed to get them back in. She said the facility had elopement training pretty regularly and they always discussed if the door alarm went off to go and checked that a resident did not leave before turning off the alarm. During an interview on 03/02/2026 at 2:42PM DON said she began working at the facility on 02/01/2026 and she did not know all the residents yet, but she assumed that Resident #1 had wandering behaviors because he had a wander guard. She said she had a chart in her office with a list of the residents with wandering behaviors and Resident #1's name was on that list. She said her expectation as the DON was that everyone should answer the door alarm by going to the door, opening the door, and looking around outside for a resident. She said if a resident eloped, they could get hit by cars; they could get lost. The DON said there was a reason residents had a wand guard and it was for their safety. Review of facility policy Risk Management Elopement dated 11/01/2019 reflected the policy was 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. Record review of Resident #1's Elopement assessment dated [DATE] reflected Resident #1 was a high elopement risk. Record review of Resident #1's Progress Notes reflected Resident #1 was discharged to another facility on 02/11/2026. Record review of all elopement assessments was conducted on 02/08/2026 for all facility residents. Seven residents were evaluated as having a high risk of elopement. Review of the seven residents care plans reflected all residents identified had a focus and interventions for high-risk elopement. Record review of in-service from HOH to FT dated 02/09/2026 reflected FT was in-serviced that all door alarms must be checked by looking outside for a resident before the alarm was turned off. Record review of facility all staff in-services dated 02/08/2026 and 02/09/2026 for Elopement Procedure: any time you turn a door alarm off, staff must check outside for residents first, policy on missing residents - what to do, who to contact, and steps to take, risk management elopement - safely and timely redirecting residents to a safe environment and facility abuse and neglect policy. Record review of facility elopement binder reflected it included a photograph of each of the residents who were identified as an elopement risk after facility wide resident elopement assessments completed on 02/08/2026. The binder included a flyer that could be presented to law enforcement and passed out to the public with the residents' current photo, name, and telephone number of the facility, name of residents' doctors. The binder included the residents' face sheets, complete resident profiles with description of each resident, mental condition and address and telephone number of relative or friend to contact, and list of residents' medications. Review of documentation of facility door alarm checks by the Administrator dated 02/08/2026 at 1:30 pm reflected that the facility front door, 200 door, 100 hall exit door 1, 100 halls exit door 2, kitchen door, 500 hall doors (all facility doors) were functioning and alarms sounded when crash bar were pushed. Review of documentation of resident wander guard checks by the DON dated 02/08/2026 reflected that all seven residents wearing wander guards activated when the residents were taken near all facility doors. During an interview on 02/27/2026 at 6:13 PM LVN C said she was in-serviced on 02/08/2026 when Resident #1 eloped. She said during the in-service it was explained that staff members do not just turn off the alarm if it is ringing. LVN C said staff should open the door and lookout to make sure no residents had gotten out of the facility. During an interview on 02/27/2026 at 6:23 PM CNA B said she was in-serviced on 02/08/2026 what to do if a resident pushed an exit door and the alarm went off. CNA B said staff should go to the scene and go outside and make sure that a resident was not out there before. She said you look for the resident before turning off the alarm. During an interview on 02/27/2026 at 6:30 PM RN B said she was in-serviced on 02/08/2026 about making sure that when an alarm goes off that staff open the door and look for a resident before turning off the alarm. She said a resident could quickly leave the facility and staff needed to make sure they did not leave the facility. Noncompliance at the IJ Level that was identified on 2/27/2026 and facility ADM was informed at 10:10 PM, 2/27/2026. The noncompliance was corrected prior to the surveyor entering the facility. The noncompliance was identified as PNC. The IJ began on 02/08/2026 and ended prior to 2/27/2026.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for one (Resident #1) of six residents reviewed for infection control CNA A failed to cleanse the perineal area (vaginal area), change her gloves, wash her hands and dispose of the soiled brief in a designated container during incontinent care for Resident #1. This failure could place residents at risk of cross contamination which could result in infections or illness. Findings included:Record review of Resident #1's face sheet dated 1/13/2026 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of unspecified dementia (a brain condition effecting memory and daily decision-making skills), anxiety disorder and heart failure. Record review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 9 indicating moderate cognitive impairment. Resident #1 was always incontinent of bowel and bladder and dependent with toileting hygiene.Record review of Resident #1's care plan dated 12/20/2023 reflected that she had an activity of daily living self-care performance deficit related to limited range of motion in her hands/wrists. Interventions included TOILET USE: The resident is dependent on 1 staff for toileting needs. Incontinent care with disposable brief use.In observation of perineal care on 01/13/2026 at 1:30 p.m. CNA A and CNA B entered Resident #1's room. CNA A unfastened Resident #1's brief and had her roll over to CNA B to assist her with holding Resident #1 over. CNA A wiped Resident #1's buttocks with a wet wipe using multiple passes with the same wipe, throwing the soiled wipes and brief on the floor. CNA A then obtained a clean brief without washing her hands or changing her gloves and applied the clean brief. CNA A picked up the soiled brief from the floor and placed it in a plastic bag provided by CNA B. CNA A covered the resident up and lowered the bed. In an interview on 01/13/2026 at 1:55 p.m. CNA A stated she had been checked off on perineal care one time since she had started working at the facility about a year ago. She stated she should have cleaned the resident's front perineal area first prior to rolling her over and cleaning her buttocks. She stated she knew she should have wiped 1 time and changed the position on her rag changed her gloves and washed her hands between the dirty brief and clean brief. She stated she was just nervous. CNA A stated she was told not to put the brief in the trash can and that was a violation. She stated she should have placed the dirty soiled brief in a bag and not directly on the floor, she stated all those things would spread germs resulting in infections for residents. In an interview on 01/13/2026 at 2:10 p.m. the DON stated she had started at the facility about 1 month ago. She stated she had not had the chance to do CNA skills check offs and had a meeting planned with them to do that within the next few weeks. She stated she expected the CNAs to follow perineal care and the handwashing policy. The DON stated she and the ADON were responsible for monitoring CNA performance check offs. The staff were trained by the nurse managers for competence. The ADON was the infection preventionist. She stated that Resident #1 had not had any urinary infections of which she was aware. She stated that the CNAs were instructed not to place the soiled briefs in the trash can because they were not removing them from the rooms. She stated they were instructed to place them in a bag and remove them when completed with brief change. She felt as if there was a misunderstanding with that information. She stated the risk for residents not receiving proper perineal care was infection. Record review o facility policy titled Perineal Care dated 10/01/21 reflected: To provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Wash perineal area, wiping from front to back. Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches.) Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward strokes. Do not reuse the same side of the disposable wipe, change the surface position of the disposable wipe, and/or obtain a clean wipe to clean the urethra or labia. Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry your hands thoroughly.Record review of Facility policy titled Handwashing/Hand Hygiene reflected: Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before moving from a contaminated body site to a clean body site during resident care; After contact with a resident's intact skin, After personal use of the toilet or conducting your personal hygiene.

Based on interviews and records review, the facility failed to ensure that medical records were accurately documented for one (Resident #1) of eight (8) residents reviewed for accurate clinical records, in that: The facility failed to ensure assessments for Resident #1 were documented in the medical record after he was discovered with ants on him while lying in bed on 10/22/2025. This deficient practice could result in errors in care and treatment and violate resident rights.Findings included: Review of face sheet dated 10/24/2025 revealed a 65-yer-old man with an initial admission date of 6/10/2022 and a recent admission date of 3/27/2025 with diagnoses that included hemiplegia and hemiparesis (paralysis and weakness on one side of the body), Chronic Obstructive Pulmonary Disease (COPD - group of breathing disorders), Type 2 diabetes (blood sugar disorder) sepsis (infection throughout the body) and dementia (memory disorder). Review also revealed Resident #1's RP and POA was listed as his FM.Review of Resident #1's quarterly MDS dated [DATE], reflected a BIMS score of 10, suggesting mild cognitive impairment. Review of Resident #1's care plan reflected the focus: The resident has a terminal prognosis and is under hospice services with [hospice company] since 05/19/25 with the goal of The resident's comfort will be maintained through the review date and an intervention Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Review of progress notes dated 10/24/2025 at 11:57 am, reflected no progress notes on 10/22/2025 regarding resident being found with ants on his body, an assessment being completed or that Resident #1's RP was contacted.During an interview on 10/24/2025 at 1:06 pm, LVN A stated she was making rounds around 6:30 in the morning on 10/22/2025 and noticed ants on Resident #1. She stated she noticed two ants crawling on Resident #1: one on his forehead and one on his throat. She stated the ant on his throat was consuming food deposits on his neck area and the other ant was just crawling across his forehead. She stated Resident #1 often ate at night and he had food deposits all over his gown and bed. She stated she did not notice ants on the floor, resident's bed or anywhere else on Resident #1. She stated she did a quick assessment of Resident #1, and no bites were noted. She stated she told the DON about it, and he said he would handle it, so she had not documented anything in the EMR.During a second interview on 10/24/2025 at 1:14 pm, LVN A stated she did not document her finding of ants or her assessment in the EMR because she was told by the ADON not to document anything in her charting about it. She stated the ADON told her she did not have to make out an incident report because there were no bites and no harm done, so she followed the ADON's instructions. She stated she was conflicted by what to do and as a nurse she is supposed to document in the resident's chart when something happens. During an interview on 10/24/2025 at 1:32 pm, the ADM stated he was aware ants had been found in Resident #1's room as it was discussed in the morning meeting on 10/23/2025. He stated the room had been cleaned and treated and they had a regular pest control program. He stated he was not aware until today that Resident #1 had ants on him, he was told there were ants in the room by the wall. He stated his expectation is that staff would have assessed residents for any injury and documented in the EMR. During an interview on 10/24/2025 at 1:49 pm, the DON stated he was aware of the ants being found on Resident #1 on 10/22/2025. He stated he had told LVN A she could go back to work, as she was passing medications that morning and he would take care of it. He stated he had done a complete head to toe assessment of the resident for any injury or skin issues, and none were found. He stated he had documented his assessment of Resident #1 in the Standards of Care book but did not put anything in the EMR. He stated the Standards of Care book was not part of the resident's medical record. He stated he had reviewed Resident #1's progress notes and had not found any documentation of the assessments done after the ants were found. During an interview on 10/24/2025 at 2:24 pm, the ADON stated LVN A had informed her of the ants being found on Resident #1. She stated, I think [LVN A] might have misunderstood me. She stated she did not mean don't document what happened in the medical record, she meant that an incident report didn't need to be done. She stated she had not documented anything in the EMR on Resident #1 being found with ants on his body. Review of Standards of Care book revealed the following entry under Quarterly Service Intensive Families: [Resident #1], Ants found in room/on resident bed/no bites noted, skin, warm, dry intact, cleaned, placed request for pest control in maintenance log Review of facility policy Charting and Documentation revised July 2017, revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 2. The following information is to be documented in the resident medical record:a. Objective observations.b. Medications administered.c. Treatments or services performed.d. Changes in the resident's condition.e. Events, incidents or accidents involving the resident; andf. Progress toward or changes in the care plan goals and objectives.

Based on interview and record review, the facility failed to provide pharmaceutical services which includes the accurate acquiring, receiving, dispensing and administering of medications to meet the needs for one resident (Resident #1) of 6 residents reviewed for pharmacy services, in that: 1) The facility failed to administer medications correctly on 10/3/2025 at 6:00 am.2) The facility failed to administer medications correctly on 10/3/2025 at 4:00 pm.3) The facility failed to administer medications correctly on 10/5/2025 at 8:00 am This failure placed residents at risk for medical errors, complications, decreased quality of life and hospitalization.Findings included:Review of Resident #1's face sheet dated 10/16/2025 reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included: type 2 diabetes (blood sugar disorder), hyperlipidemia (high cholesterol), chronic obstructive pulmonary disease (breathing disorder), hypertension (high blood pressure), seizures (temporary episode of abnormal electrical activity in the brain) and cerebral infarction (blood flow to the brain is blocked or interrupted). Review of Resident #1's MDS assessment dated [DATE], type 99 = none of the above, reflected no entry for BIMS score, but an entry under staff assessment for mental status as 0, indicating Memory OK and an entry of 1, indicating Modified independence - some difficulty in new situations only for Cognitive Skills for Daily Decision Making Review of Resident #1's orders reflected orders dated 10/3/2025:lamotrigine Oral Tablet 25 MG (Lamotrigine) Give 2 tablet by mouth two times a day for seizure [sic].Pregabalin Oral Capsule 200 MG (Pregabalin) Give 1 capsule by mouth three times a day for neuropathy] (nerve damage that can cause numbness, tingling, and pain). Review of Resident #1's progress notes on 10/16/2025 reflected no entries on 10/3/2025 or 10/5/2025 concerning medication errors or issues. Review of Resident #1's pain assessment dated [DATE] on dayshift reflected LVN C noted her pain to be 0. Review of Resident #1's vital signs assessment dated [DATE] on dayshift reflected her vital signs had been charted by LVN C and were all within normal limits. Review of Resident #1's October 2025 MAR on 10/16/2025 reflected that:The Lamotrigine medication administration was signed off on 10/3/2025 for the 6:00 am dose by LVN A.The Lamotrigine medication administration was signed off on 10/3/2025 for the 4:00 pm dose by LVN B.The Pregabalin medication administration was signed off on 10/5/2025 for the 8:00 am dose by LVN C. Review of Resident #1's Controlled Drug Administration Record (CDAR) dated 10/3/2025 reflected that:One tablet of Lamotrigine was given on 10/3/2025 at 5:58 am by LVN AOne tablet of Lamotrigine was given on 10/3/2025 at 4:45 pm by LVN BNo entry for Pregabalin administration on 10/5/2025 at 8:00 am. During an interview on 10/16/2025 at 11:17 am, FM stated Resident #1 was admitted to the facility on [DATE] for a respite stay (temporary period of care for an individual, giving the primary care giver a break).] They stated they gave the medication bottles to the nurse and the pill counts were on the label of each medication bottle. FM stated the nurse had not counted the medications with them or provided them with a sign off sheet on the medications and their counts. FM stated they picked up the medications on 10/8/2025 and the counts looked off on several of the bottles and FM suspected Resident #1 did not get her medications as ordered which concerned them because this was the first time the FM had utilized respite services for Resident #1. During an interview on 10/16/2025 at 3:00 pm the ADM stated he was not aware of the medication errors until this investigator informed him and showed him the count sheets. He stated the med errors should have been reported. He also stated his expectation is that staff will follow orders for medications. During an interview on 10/16/2025 at 3:25 pm, LVN C stated he worked the morning shift on 10/5/2025 and passed medications to Resident #1. He stated if he signed the Pregabalin off in the MAR then I think I gave it. He stated he was not sure why he had signed it off in the MAR and not on the CDAR. He then stated he was not sure if he gave the Pregabalin medication or not. He stated that not giving medications but signing them off would have been a med error and med errors need to be reported to the DON so they can investigate He stated Resident #1 had neuropathy and not getting her Pregabalin medication could have caused the potential for neuropathic pain. LVN C stated he had not recalled Resident #1 complaining of pain. During an interview on 10/16/2025 at 4:25 pm, LVN D stated she relieved LVN A on the morning on 10/4/2025 and LVN A told her she and LVN B had only given one tablet of Lamotrigine, and it should be two. LVN D stated LVN B told her to make sure you give two on this round. LVN D stated she did not report this to anyone because she was just coming on shift, and she assumed LVN A would have let the DON know of the errors. She stated she was aware that med errors needed to be reported immediately to the DON. During an interview on 10/21/2025 at 5:59 pm, LVN A stated she had worked the night shift on 10/3/2025 and gave given Resident #1 her medications. She stated she had given Resident #1 one tablet of Lamotrigine for each dose instead of two because the FM had written the instructions out on a piece of paper and that's what she followed. She stated she was the one that put the order in the EMR, and the order matched what was on the bottle, but not what the FM wrote on the paper. LVN A stated she did not notice the error until her and LVN D discussed the discrepancy on the morning on 10/4/2025 and that's when she discovered the paper and bottle did not match. She stated what was on the bottle was the actual doctor's order and that's what she should have followed. She stated med errors should have been reported to the DON, and she had not been aware it was a med error until after it had happened and she did not report it. LVN A stated she was not sure why she had signed off the MAR indicating she had given two tablets of Lamotrigine when she only gave one tablet. She stated the order is in the MAR and they are supposed to go by the MAR. She stated some potential problems for not following orders could be a med error and Resident #1 was taking Lamotrigine to prevent seizures so resident could have possibly had a seizure. She stated, I always follow the MAR; except for that case. During an interview on 10/22/2025 at 11:58 am, MD stated he had just become aware of the medication errors today and was the medical director at the time of these incidents. He stated his expectation is that medications will be given as ordered and this is the implicit trust that the healthcare system is built on. He stated he also expected staff to contact the physician on call when there are med errors or discrepancies. He stated with Resident #1 only getting half of her required doses of the Lamotrigine on 10/3/2025 there could have been a little dip in serum levels, but he would have expected any s/s to show up within 24 hours and to his knowledge this did not happen. He stated with Resident #1 missing one dose of the Pregabalin on 10/5/2025, the resident could have had breakthrough pain but the missed dosage was not clinically significant if this had not occurred and he did not get reports of this happening. During an Interview on 10/22/2024 at 2:44 pm, the interim DON stated he expected staff to follow the MAR and follow orders. He stated medications errors should be reported immediately, and he was not aware of these errors until this investigator brought it to his attention. He stated, it should not have happened, and it was sad that it did. But to his knowledge there was no adverse effect on Resident #1. Attempts to interview/return calls to LVN B were made on 10/21/2025 at 5:03 pm, 10/22/2025 at 12:45 pm and 10/23/2025 at 11:15 am but were unsuccessful. Review of facility policy Administration Procedures for All Medications, effective 09-2018, reflected: Policy: Medications will be administered in a safe and effective manner. The guidelines in this policy apply to all medications. III. 5 Rights (at a minimum)At a minimum, review the 5 rights at each of the following steps of medication administration.1. Prior to removing the medication package/container from the cart/drawer:a. Check the MAR/TAR for the order.b. Note any allergies or contraindications the resident may have.c. If unfamiliar with the medication, consult a drug reference, manufacturer package insert, or pharmacist for more information.d. Check for vital signs or other tests to be done during or prior to medication administration.e. Prepare the resident for medication administration.2. Prior to removing the medication from the container:a. Check the label against the order on the MAR.b. Note any supplemental labeling that applies (fractional tablet, multiple tablets, volume of liquid, shake well, give with another medication, etc.). IV. Administration7. After administration, return to cart, replace medication container (if multi-dose and doses remain), and document administration in the MAR or TAR and the controlled substance sign out record, if necessary.

Based on interview and record review, the facility failed to immediately notify the residents' representative of the changes in the resident's physical and mental health for one (Resident #1) of seven residents reviewed for notification of changes. The facility failed to ensure Resident #1's RP was notified when he was found with ants on him while lying in bed on 10/22/2025. This failure placed residents at risk of a decreased quality of life and risk of not having their responsible party represent them in medical and care decisions.Findings included: Record review of Resident #1's face sheet dated 10/24/2025 revealed a 65-yer-old man with an initial admission date of 6/10/2022 and a recent admission date of 3/27/2025 with diagnoses that included hemiplegia and hemiparesis (paralysis and weakness on one side of the body), Chronic Obstructive Pulmonary Disease (COPD - group of breathing disorders), Type 2 diabetes (blood sugar disorder) sepsis (infection throughout the body) and dementia (memory disorder). Review also revealed Resident #1's RP and POA was listed as his FM. Review of Resident #1's quarterly MDS dated [DATE], reflected a BIMS score of 10, suggesting moderate cognitive impairment. Review of Resident #1's care plan reflected the focus: The resident has a terminal prognosis and is under hospice services with [hospice company] since 05/19/25 with the goal of The resident's comfort will be maintained through the review date and an intervention Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Record review of Resident #1's progress notes dated 10/24/2025 at 11:57 am, reflected no progress notes on 10/22/2025 regarding resident being found with ants on his body or that Resident #1's RP was contacted. During an interview on 10/24/2025 at 1:06 pm, LVN A stated she was making rounds around 6:30 in the morning on 10/22/2025 and noticed ants on Resident #1. She stated she noticed two ants crawling on Resident #1: one on his forehead and one on his throat. She stated the ant on his throat was consuming food on his neck area and the other ant was just crawling across his forehead. She stated Resident #1 often ate at night and he had food all over his gown and bed. She stated she did not notice ants on the floor, resident's bed or anywhere else on Resident #1. She stated she did a quick assessment of Resident #1, and no bites were noted. She stated she told the DON about it, and he said he would handle it, so she had not documented anything or called Residents #1's RP to notify her. She stated if RPs were not notified, then they might not know what is going on with the resident.During an interview on 10/24/2025 at 1:14 pm, HN stated she found out about the ants on Resident #1 on 10/23/2025 when she had come to the facility for his normal visit. She stated she came to visit resident on Mondays and Thursdays. She stated she had not notified the RP, because no one had notified her until the next day when she had come to the facility. She stated she had assessed the resident and had not noticed any insect bites on him in the area where the staff had told her they found the ants. During an interview on 10/24/2025 at 1:32 pm, the ADM stated he was aware ants had been found in Resident #1's room as it was discussed in the morning meeting on 10/23/2025. He stated the room had been cleaned and treated and they had a regular pest control program. He stated he was not aware until today that Resident #1 had ants on him, he was told there were ants in the room by the wall. He stated his expectation is that staff would have assessed resident for any injury, documented in the EMR and notified the RP. During an interview on 10/24/2025 at 1:49 pm, the DON stated he was aware of the ants being found on Resident #1 on 10/22/2025. He stated he had told LVN A she could go back to work, as she was passing medications that morning and he would take care of it. He stated he had done a complete head to toe assessment of the resident for any injury or skin issues, and none were found. He stated he did not document his assessment of Resident #1 in the EMR and had not called the RP or hospice. He stated he believed the hospice CNAs were verbally informed of the ants when they came to provide care for Resident #1 in the morning on 10/22/2025. During an interview on 10/24/2025 at 2:50 pm, FM stated she was not aware Resident #1 had been found with ants on him while lying in bed. FM stated the facility is usually pretty good about letting her know what's going on with Resident #1, so it bothered her that no one called her. She stated Resident #1 was partially paralyzed and doesn't always feel everything so having ants on him could have been a problem - if they bit him, he may not have even noticed it. Review of Pest Control logbook on 10/24/2025 reflected an entry on 10/22/2025 noting ants were found around Resident #1's bed, it was reported by LVN A and pest control was coming 10/24/2025.A facility policy on Resident Rights was requested on 10/24/2025 via email at 10:45 am but was never received.

Based on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment for 1 (Resident #1) of 5 residents reviewed for environment. The facility failed to ensure Resident #1 was provided clean bed linens that were in good condition. This failure placed residents at risk of living in an uncomfortable environment leading to a diminished quality of life. Findings included: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Diabetes Mellitus with Diabetic Nephropathy (elevated blood sugar that has caused kidney damage) and constipation. Record review of Resident #1's Baseline Care Plan, dated 06/17/2025, reflected Resident #1 was dependent for transferring from chair to bed and bed to chair, toileting hygiene, showering and bathing, and lower and upper body dressing. The care plan reflected Resident #1 was always incontinent of bowel and bladder and used a wheelchair for mobility. Record review of Resident #1's admission MDS assessment dated [DATE], reflected the resident had a BIMS score of 14, which indicated she was cognitively intact. In an interview and observation on 07/01/2025 at 12:00 PM Resident #1was lying in bed, her hair was unbrushed, and her clothing had food crumbs on it. Her sheets had a urine odor. She stated she was not ok. She stated she had not been showered in 8 days. She stated she had asked to get up but was told she must stay in the bed today. She pointed to her sheets at a basketball size brown dried stained ring on her Resident #1 sheets. She then pulled her sheet back and rolled to the side revealing 2 (two) additional large brown rings under her padding that was placed on the bed between her body and the bottom fitted sheet. She stated not being clean made her feel dirty and trashy. In an interview on 07/01/2025 at 12:10 PM CNA A stated she had been a certified nurse aide since January 2025, but this was her fourth day at this facility. She stated she received 2 days of orientation in the facility. She stated she had not worked with Resident #1 prior to today. She stated she had received a verbal report from the nurse this morning on residents needs and was told to not get Resident #1 up out of bed. She stated she did not realize Resident #1's bottom bed sheets were stained. She stated the CNAs were responsible for changing residents' sheets. She stated having dirty sheets would make the residents feel dirty. In an interview on 07/01/2025 at 12:15 PM CNA B stated she was responsible for resident transfers to and from appointments but was assisting on the floor today. She stated there were 2 staff members that did call in today, so the staff were all working together to meet the needs of the residents. She stated she was not aware Resident #1 had brown stained sheets. CNA B stated the CNAs were responsible for changing residents' sheets. She stated she was heading to assist the other CNA A to help clean Resident #1 up now. She stated not having clean sheets could impact a resident negatively. She stated it could bother the resident and make them uncomfortable and feel dirty. In an interview on 07/01/2025 at 1:45 PM LVN C stated she had worked at the facility for 2 years. She stated Resident #1 was a new admit to the facility. She stated she did tell CNA A that Resident #1 did not get up for breakfast. She stated the aide must have misunderstood her and left Resident #1 in bed. LVN C stated if Resident #1 asked to get up then the staff should get her up. LVN C stated the CNAs were responsible for changing residents' sheets. She stated sheets were to be changed on shower days and as needed if soiled. She stated no residents should be left in dirty sheets. She stated leaving a resident in dirty sheets and not showered could impact their dignity making a resident depressed. In an interview on 07/01/2025 at 2:30pm The Director of Clinical Operation stated she expected residents' bed sheets were changed on shower days and as needed. She stated the facility practice was to throw away stained or worn sheets in the trash to ensure they were not used on residents' beds. She stated leaving a resident in soiled or dirty sheets, physically it can cause skin breakdown, emotionally it can make them feel unclean. Record review of the undated facility's policy titled Quality of Life Homelike Environment reflected Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. 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 Clean, sanitary, and orderly environment and clean bed and bath linens that are in good condition.

Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 1 of 5 residents (Resident #1) reviewed for ADLs. The facility failed to ensure Resident #1 received showers on 06/18/2025, 06/23/2025, 06/27/2025, and 06/30/2025. This failure could place residents at risk of not being provided care and assistance when needed. Findings Included: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Diabetes Mellitus with Diabetic Nephropathy (elevated blood sugar that has caused kidney damage) and constipation. Record review of Resident #1's Baseline Care Plan, dated 06/17/2025, reflected Resident #1 was dependent for transferring from chair to bed and bed to chair, toileting hygiene, showering, bathing, lower and upper body dressing. The care plan reflected Resident #1 was always incontinent of bowel and bladder and used a wheelchair for mobility. Record review of Resident #1's admission MDS assessment dated [DATE], reflected the resident had a BIMS score of 14, which indicated she was cognitively intact. Record review of Resident #1 Documentation Survey Report V2 (a report reflecting care provided to the resident) reflected Resident #1 was assigned to receive her shower every Monday, Wednesday, and Friday. The report reflected Resident #1 did not receive her showers on 06/18/2025, 06/23/2025, 06/27/2025, and 06/30/2025. There was no documentation of Resident #1 refusing her showers. Record review of Resident #1's Progress Notes dated 06/17/2025 through 07/01/2025 reflected there was no documentation of Resident #1 refusing care. In an interview and observation on 07/01/2025 at 12:00 PM Resident #1was lying in bed, her hair was unbrushed, and her clothing had food crumbs on it. Her sheets had a urine odor. She stated she was not ok. She stated she had not been showered in 8 days. She stated she had asked to get up but was told she must stay in the bed today. She pointed to her sheets at a basketball size brown dried stained ring on her sheets. She then pulled her sheet back and rolled to the side revealing 2 addition large brown rings under her padding that was placed on the bed between her body and the bottom fitted sheet. She stated not being clean made her feel dirty and trashy. In an interview on 07/01/2025 at 12:10 PM CNA A stated she had been a certified nurse aide since January 2025, but this was her fourth day at this facility. She stated she received 2 days of orientation in the facility. She stated she had received a verbal report from the nurse this morning on residents needs and was told to not get Resident #1 up out of bed. She stated the CNAs were responsible for giving Resident #1 a shower and cleaning her. She stated she was not sure of Resident #1's shower days. She stated not getting showers would make the resident feel dirty. In an interview on 07/01/2025 at 12:15 PM CNA B stated she was responsible for resident transfers to and from appointments but was assisting on the floor today. She stated she was not sure when Resident #1 had her last shower. She stated that the shower schedule was at the nurse's station. She stated she was heading to assist the other CNA to help clean Resident #1 up now. She stated not having been showered could impact a resident negatively. She stated it could bother the resident and make them uncomfortable and feel dirty. In an interview on 07/01/2025 at 1:45 PM LVN C stated she had worked at the facility for 2 years. She stated Resident #1 was a new admit to the facility. She stated her showers were scheduled for 2pm-10pm shift on Monday, Wednesday, and Friday. She stated the aides looked at the shower book to find out who needed showers and what days. She stated she was telling CNA A that Resident #1 did not get up for breakfast. She stated the aide must have misunderstood her and left Resident #1 in bed. She stated if Resident #1 asked to get up then the staff should get her up. She stated residents should get their showers on shower days and as needed. She stated Resident #1 has not refused showers that she was aware of. She stated if a resident were to refuse a shower, then the nurses must follow up and document the refusal. She stated leaving a resident dirty and not showered could impact their dignity making a resident depressed. In an interview on 07/01/2025 at 2:30pm The Director of Clinical Operations stated she expected showers to be completed on a resident's assigned shower days. She stated the nursing assistants were responsible for showers. She stated the certified nursing assistants had access to the Kardex which gives a detailed schedule of residents' needs including shower days and schedule. She stated there was also a schedule for residents' showers at the nurse's station. She stated the nurse aides were instructed on the Kardex and shower schedule upon orientation. She stated she was not aware of Resident #1 refusing any showers. She stated the nurse should have followed up with any shower refusal. She stated not bathing a resident routinely physically it can cause skin breakdown, emotionally it can make them feel unclean. Record review of the undated facility's policy titled Quality of Life-Resident Self Determination reflected Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life including Daily routine, such as sleeping and waking, eating, exercise and bathing schedules.

Based on observation, interview and record review, the facility failed to provide residents with an ongoing resident centered activity program, designed to meet the interests of and support the physical, mental, and psychosocial well-being of 3 (Residents #25, #31, and #42) of 8 residents reviewed for activities. The facility failed to provide activities as scheduled from January 23, 2025, through February 12, 2025. This failure placed residents at risk of boredom, depression, isolation, and a diminished quality of life. Findings include: Record review of Resident #25's face undated sheet reflected a [AGE] year-old male initially admitted to the facility on [DATE], and readmitted on [DATE], with the following diagnoses: Type 2 Diabetes Mellitus (a chronic disease that causes a person's blood glucose levels to rise too high) Chronic Pulmonary Edema (a condition where fluid accumulates in lung tissues, making it difficult to breathe), Acute Respiratory Failure with Hypoxia (acute impairment in gas exchange between the lungs and the blood), Major Depressive Disorder (a mood disorder characterized by persistent feelings of sadness), and Anxiety Disorder (mental disorder characterized by significant and uncontrollable feeling of anxiety and fear that affect daily life). Record review of Resident #25's Annual Comprehensive MDS assessment dated [DATE], revealed Resident #25's activity preferences of strong importance to him were: listening to music, being around animals such as pets, keeping up with the news, doing things with groups of people, going outside when the weather is good, and participating in religious services and practices. Record review of Resident #25's Quarterly MDS assessment dated [DATE], revealed Resident #25 had a BIMS score of 12, indicating intact cognition. Record review of Resident #25's Comprehensive Care Plan focus dated 1/17/2025 regarding activities revealed Resident #25 attended most events, but also liked to do individual activities in his room. Resident #25's goal was to continue to participate in at least 4 activities per week. Interventions included posting calendars in the resident's room, reminding and encouraging the resident, thanking the resident for participating, allowing the resident to refuse to participate [in activities], and promoting the resident's love of music and storytelling with staff and other residents. Record review of Resident #31's undated face sheet, reflected a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: Major Depressive Disorder (a mood disorder characterized by persistent feelings of sadness), Muscle Weakness, Pulmonary Fibrosis (a condition in which the lungs become scarred over time causing breathing difficulties), need for assistance with personal care, and difficulty walking. Record review of Resident #31's Comprehensive Care Plan initiated on 4/27/2022, revealed the focus regarding activities to be self-directed activities. Resident #31's goal regarding activities was to continue to do Bible studies with other residents through the next review date. Interventions included posting activity calendars in the resident's room, assisting the resident with activities when he agrees to participate, and praising and thanking the resident for attending an activity. Record review of Resident #31's Annual Comprehensive MDS assessment dated [DATE], revealed Resident #31 had a BIMS score of 15, indicating intact cognition, a very important activity preference of participating in religious services or practices, and a somewhat important activity preference of going outside when the weather is good. Record review of Resident #42's undated face sheet, reflected a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: Type 2 Diabetes with Diabetic Autonomic (Poly)Neuropathy (a chronic disease that causes a person's blood glucose levels to rise too high; damage to multiple nerves in the peripheral nervous system in different parts of the body at the same time), Disorder of the teeth and supporting structures, muscle weakness, and Depression. Record review of Resident #42's Admission MDS assessment dated [DATE], revealed having books, newspapers, and magazines to read, and listening to music he likes as being very important activity preferences. Record review of Resident #42's Comprehensive Care Plan initiated on 10/13/2022 and revised on 12/27/2023, revealed the resident's activity-related focus to be attending activities of his choice and that the resident will speak his mind and let you know when something is wrong. Resident's #42's activity related goal was to continue to participate in at least 3 activities per week. Interventions included posting an activity calendar in the resident's room, reminding and encouraging the resident daily, promoting the resident's activity ideas and ability to express himself, and the resident's joy and talent in playing the piano, singing, and doing artwork such as drawing. Record review Resident #42's Quarterly Activity Participation Review dated 11/27/2024 revealed the resident attends most large events. The resident's favorite activity and interest were smoking and cooking. The resident's activity-related focuses, goals, and interventions remained the same. Record review of Resident #42's Quarterly MDS assessment dated [DATE], revealed Resident #42 had a BIMS score of 15, indicating intact cognition. Observation and interview 2/11/2025 at 10:11AM, revealed Resident #42 sitting in a chair at the foot of his bed watching a game show on television. Resident #42 expressed boredom and disinterest in watching television, but stated this was something to do to pass the time as there was nothing else to do. Resident #42 stated the activities offered at the facility are not good or of interest to him. The resident stated that lately no activities have been offered. The resident stated that the facility's activity director was fired, and no one had assumed activity duties The resident stated that prior to the activity director's termination, the activity calendar was not being followed. The resident stated that occasionally they played BINGO, but it had been a while. Resident #42 stated the activities program has always been inconsistent and unorganized. The resident stated that suggestions for activities and activity spaces go ignored. Resident #42 stated that he would like more community involvement. He stated that pet therapy and church services stopped because the providers were not allocated a specific time or space to provide the services. Resident #42 stated that the residents need more than occaisonal parties. He stated the residents need activities that enhance their well-being and morale, and that promote positive feelings toward facility staff. Resident #42 stated life at the facility is the same every day, with most residents spending their time watching television with no socializing. Observation of the facility on 2/10/2024, through 2/12/2024, from approximately 9AM-4PM daily, revealed no formal activities being provided to the residents. Observation of the facility activity room on 2/11/2025 at 3PM, revealed no coordinated activities being offered. The television in the activity room was on with 2 residents quietly watching without conversation or interaction with each other. No staff were present in the activity room. It did not appear as if any activity had been provided immediately prior to observation or that any activity was being set up or coordinated in the activity room to be provided following observation. The activity room was orderly and appeared undisturbed. The activity room contained a bookshelf with approximately 20 books, one jigsaw puzzle, and a few videos and audio books. The extra-large, printed activity calendar posted in or near the activity room was observed to be for January 2025, not February 2025. In an interview on 2/11/2025 at 10:59AM, Resident #25 reported the facility was not offering activities as the facility had no AD on staff. The resident stated that the scheduled Valentine's Day party had been cancelled. The resident stated that the last time the residents were provided with an activity was 2 weeks prior, when they were given popsicles. In an interview on 2/11/2025 at approximately 1:15PM, Resident #31 stated the facility was not offering activities. The resident stated that it had been about 2 weeks since any activity was provided. In an interview on 2/12/2025 at 11:16AM, the ADM stated the activity director position is currently vacant as the FAD abruptly vacated the position without notice. The ADM stated that the FAD's last physical day of work was on 1/22/2025. The ADM stated that he and a former hospitality aide had been providing impromptu activities for the residents following the departure of the FAD until the former hospitality aide also vacated her position. The ADM stated that the former hospitality aide's last day of employment with the facility was on 2/7/2025. In an interview on 2/12/2025 at 12:45PM, LVN A stated that she is a Charge Nurse and has been employed with the facility for 4 years. LVN A said the last formal activity provided for the residents was on 2/7/2025. The activity was conducted by a former hospitality aide who no longer works at the facility. LVN A stated the therapy staff have been providing activities for the residents recently. LVN A stated the offering of activities to residents is very important because it gives the residents motivation. LVN A stated that any complaints or suggestions made by residents to her regarding activities would be typically shared during their morning meetings. LVN A said the FAD discontinued her employment with the facility 2 weeks ago. LVN A said she is unsure of who is responsible for making sure the activity calendar has been followed since the FAD left. LVN A said she doesn't know if activities have been provided as listed on the activity calendar. In an interview on 2/12/2025 at 12:50PM, the COTA said she has been employed with the facility for 2 years. The COTA stated that the therapy department staff have been assisting with activities. The COTA stated that the therapy staff help set up games and puzzles for the residents in the activity room, and the therapy room is always open to residents. The COTA stated therapy staff do not provide scheduled activities for the residents. The COTA stated the last formal activity provided to the residents was on 2/7/2025. The COTA stated the quality of activities offered to the residents could be better, but she believes this will improve once a new activity director is hired and an activity calendar is established. The COTA stated there were no scheduled activities being offered on this day to her knowledge. In an interview on 2/12/2025 at 12:50PM, the PTA stated she has been employed with the facility for 2 years. The PTA said the therapy department staff have been helping with activities when they can. Their assistance consists of setting up activities and supporting the residents. In an interview on 2/12/2025 at 12:50PM, the RD stated he has been employed with the facility for 2 months. The RD stated the therapy staff have been providing impromptu activities for residents when they can. The RD said these activities are not scheduled and the therapy staff are not responsible for following the activity calendar. The RD said therapy staff assist with setting up activities in the activity room. The RD stated activities are an important because they promote positivity, give residents something to do, improve residents' quality of life, and provide opportunities to socialize. In an interview on 2/12/2025 at 12:55PM, the ADM stated the residents complained about the lack of activities during the Resident Council meeting on 2/5/2025. The ADM stated the lack of activities was due the vacant activity director position. The ADM stated that he is in the process of hiring a new activity director. The ADM stated that he plans to continue to use other staff members to assist with activities until a new activity director is hired. The ADM stated that activities would be provided as scheduled and as listed on the activity calendar, except for the evening activities, as there are no staff available in the evening to conduct activities. The ADM stated that he recently hired HA. HA's first day of employment was on 2/10/2025. The ADM stated that HA will also help with resident activities. The ADM acknowledged that some scheduled activities have been missed, but stated that the facility is in their rebuilding stage and he expects things to improve. In an interview on 2/12/2025 at 1:01PM, HA stated that she began working at the facility this week. Her scheduled hours are 8AM-5PM. HA stated that her duties include passing out ice to the residents twice a day, assist residents with smoke breaks, assist with making residents' beds as needed, and assisting with passing and picking up meal trays as needed. HA stated that she was not aware that her duties would include assisting with activities. HA stated that she has not assisted with activities this week. HA stated that she has not been formally trained or certified as activity personnel. HA stated the benefits of activities is that they keep residents active, they can provide a form of exercise, and it allows residents to interact with each other. HA said the lack of activities for residents could cause a loss of interest in life and isolation. In an interview on 2/12/2025 at 1:04PM, the IDON stated that he has been employed with the facility for 2 months. He said that he doesn't pay attention to the activities offered to residents. He stated that the FAD was believed to be successfully carrying out the activity program for residents, but that was not be the case. The IDON stated that the residents were dissatisfied with the inconsistency of activities and the types of activities offered by the FAD. The IDON stated that the ADM is in the process of hiring a new activity director. The IDON stated that he has not assisted or provided activities for the residents. The IDON stated the benefits of activities include social enrichment, engagement, and improved quality of life. He said the lack of activities for residents could cause depression and isolation. Record review of the facility's activity calendars for January 23, 2025, through February 12, 2025, revealed the following scheduled activities: January 23, 2025: 8:30am Daily Chronicle 9:45am-Daily Devotion 11am-Karaoke 1pm-In room visits 2pm-Resident Council Meeting 3:30pm-UNO Game 6:30pm-Table Puzzles 7:30pm-Activity Cart January 24, 2025 8:30am-Daily Chronicle 9:45am-Daily Devotion 10:30am-S&C 1pm-In room visits 2pm-Birthday Party 3:30pm-Jewelry Art 6:30pm-Table Puzzles 7:30pm-Activity Cart January 25, 2025 8:30am-Daily Chronicle 9:45am-Daily Devotion 11am-Table Puzzles 1pm-In room visits 2pm-LPT 3:30pm-Make a Word Game 6:30pm-Table Puzzles 7:30pm-Activity Cart January 26, 2025 8:30am-Daily Chronicle 9:45am-Daily Devotion 11am-TBS TV in the Sunroom 1pm-In room visits 2pm-Church Service 3:30pm-Church 6:30pm-Table Puzzles 7:30pm-Activity Cart January 27, 2025 8:30am-Daily Chronicle 9:45am-Daily Devotion 11am-Tea Party 1pm-In room visits 2pm-Spelling Bee 3:30pm Let's Make a Deal 6:30pm-Table Puzzles 7:30pm-Activity Cart January 28, 2025 8:30am-Daily Chronicle 9:45am-Daily Devotion 11am-Rebus Puzzle 1pm-In room visits 2pm-Crafts & Art 3:30pm-[NAME] Game 6:30pm-Table Puzzles 7:30pm-Activity Cart January 29, 2025 8:30am-Daily Chronicle 9:45am-Daily Devotion 11am-Reading Rainbow 1pm-In room visits 2pm-Brush painting 3:30pm-Clue words 6:30pm-Table Puzzles January 30, 2025 8:30am-Daily Chronicle 9:45am-Daily Devotion 11am-Memory Lane 1pm-In room visits 2pm-Family Feud 3:30pm-Indoor Bowling 6:30pm-Table Puzzles 7:30pm-Activity Cart January 31, 2025 8:30am-Daily Chronicle 9:45am-Daily Devotion 10:30am-S&C 1pm-In room visits 2pm-Name that Tune 3:30pm-Happy Hour 6:30pm-Table Puzzles 7:30pm-Activity Cart February 1, 2025-February 6, 2025, the activities scheduled were the same as follows: 8:30am-Daily Chronicle 9:45am-Daily Devotion 11am-FF N.D. Church 1pm-In room visits 2pm-Dominos Games 3:30pm-Board Games 6:30pm-Table Puzzles 7:30pm-Activity Cart February 7, 2025 8:30am-Daily Chronicle 9:45am-Daily Devotion 11am- 1pm-In room visits 2pm- 3:30pm- 6:30pm-Table Puzzles 7:30pm-Activity Cart February 8, 2025 8:30am-Daily Chronicle 9:45am-Daily Devotion 11am- 1pm-In room visits 2pm- 3:30pm-Spades Games 6:30pm-Table Puzzles 7:30pm-Activity Cart February 9, 2025-February 12, 2025 8:30am-Daily Chronicle 9:45am-Daily Devotion 11am-FF N.D. Church 1pm-In room visits 2pm-Dominos Games 3:30pm-Board Games 6:30pm-Table Puzzles 7:30pm-Activity Cart Record review of the Activity Director job description (revised 11/2020) states in part: Position Summary: To develop and provide a comprehensive holistic resident wellness program that meets the individual interests and capabilities of the resident population. Activities will encompass the body (physical), mind (cognitive), spirit, and social engagement dimensions. Record review of the Activities and Social Services policy and procedures (revised December 2006) states in part: Residents shall have the right to choose the type of activities and social events in which they wish to participate as long as such activities do not interfere with the rights of other residents in the facility. 3. When the Care Planning Team develops the resident's activity and social care plans, the resident will be given an opportunity to choose when, where, and how he or she will participate in activities and social events. As much as possible, the facility will provide activities, social events, and schedules that are compatible with the resident's interests, physical and mental assessment, and overall plan of care. 7. Activities will be scheduled periodically during the day, as well as during evenings, weekends, and holidays.

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1of 2 medication storage rooms (room located by Hall 300). The facility failed to ensure expired medication administration supplies were removed from the medication room located by hall 300. These failures could place residents at risk for ineffective treatments, intravenous catheter dislodgements and infections. Findings include: Observation on 2/11/25 at 10:30 AM of the Hall 300 Medication Storage Room revealed the following: 8 Zyno IV Administration sets expired 3/19/2023. 7 Zyno IV Administration sets expired 6/20/2022 1 Stat lock PICC PLUS Catheter stabilizer expired 4/28/2023. 1 Central Line Dressing Kit expired 2/28/2021. In an interview on 2/12/25 at 12:48 PM LVN-A stated, the policy on expired medical supplies was to take them back to medical records department where they get rid of them. She stated the nurses, and the medication aides were responsible for checking the rooms. She said this was important because the supplies may not be good to use, and they could hurt the residents by causing infections if they were used. In an interview on 2/12/25 at 12:54 PM LVN-B stated, the policy for expired medical supplies was to pull them out of the medication storage rooms. She stated the nurses, and the medication aides were responsible for checking the medication rooms. She stated that it was important to do this because otherwise someone could grab the expired supplies and accidentally use them. She stated the negative outcome to using expired supplies was that residents could have side effects and the expired supplies could be damaged and not work properly. In an interview on 2/12/25 at 12:59 PM the DON stated, the policy for expired medical supplies was to throw them out/dispose of them. She stated she was responsible for removing expired supplies. She stated, anyone else who finds expired supplies was also responsible for removing them. She stated it was important to remove expired items because they could have lost integrity and materials could be bad which could cause IV dressings to breakdown and come off. In an interview on 2/12/25 at 1:04 PM the ADM stated, the policy on expired medical supplies was to discard them and the nurse's and the nurse supervisors were responsible for doing that. He stated it was important to discard expired items because they could lose effectiveness and then they would not stick to cover the IV sites. Record review of the facility's undated policy labeled Pharmscript-Storage of Medications Policy # 4.1, reflected: Outdated medications are immediately removed from inventory. Expired medications will be removed from the active supply and destroyed

Based on interview and record review, the facility failed to provide accurate PASRR screenings for individuals with a mental disorder for 2 (Resident #16 and Resident #52) of 14 residents reviewed for PASSAR assessments. Resident #16 did not have a new PASSAR level I screening completed or a PASSAR level II screening completed although a diagnosis of mental illness was diagnosed after the admitted . Resident #52 did not have an accurate PASSAR Level 1 screening after Resident #52 was admitted with a negative PASSAR Level 1 screening but had a mental illness. These failures could place all residents who had a mental illness or intellectual or developmental disability at risk for not receiving needed assessment, care, and services to meet their needs. Findings Included: Record review of Resident #165's Face Sheet indicated the resident was a [AGE] year-old male who admitted to the facility with an original admitted [DATE]., an initial admitted [DATE], and an admitted [DATE]. Resident #156's face sheet revealed a diagnosis of Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) on 05/15/2024. Resident #15 also had others diagnoses of Hemiplegia and Hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (complete weakness and completed paralysis of one side of the body), Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) and Unspecified Dementia (symptoms that affect memory, thinking and social abilities). Record review of Resident #15's Quarterly MDS assessment dated [DATE], revealed an active diagnosis of Anxiety Disorder, Depression, and Psychotic Disorder and a BIMS of 13 which indicates moderate cognitive impairment. Record review of Resident #15's Comprehensive Care Plan revealed a Focus Area that stated that Resident #15 was PASSAR PE negative due to primary diagnosis of dementia, despite diagnosis of MI dated 04/15/2022. Another Focus Area stated Mr. Resident #16 uses antidepressant medication related to Depression dated 01/01/2022. Record review of Resident #15's PASSAR records indicated no mental illness, intellectual disability and/or developmental disability were present on PASSAR I dated 06/10/2022 and Resident #15 did not qualify for PASSAR II or services. On 02/10/2025 at 11:15 AM an interview was attempted with Resident #16 in which the resident refused to be interviewed with state surveyor. On 02/11/2025 at 2:15 PM another additional interview was attempted with Resident #16 in which the resident had refused again an interview again. Observation on 02/10/2025 at 10:30 AM revealed Resident #52 laying in her bed in her room curled up in the fetal position asleep. Observation on 02/11/2025 at 10:22 AM revealed Resident #52 laying in her bed in her room curled up in the fetal position asleep. Record review of Resident #52's quarterly MDS assessment, dated January 29, 2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. She had diagnoses of bipolar disorder (significant mood swings), depression (feelings of sadness and loss of interest), cognitive communication deficit (brain injuries that affect a person's ability to communicate effectively), muscle wasting (loss of muscle mass), lack of coordination, and intestinal obstruction (bowel blockage). Her BIMS score was a 00, which indicated severe cognitive impairment. Record review of Resident #52's care plan dated last revised 02/09/2025 reflected resident was on an antipsychotic medication due to bipolar, dementia. Record review of Resident #52's PASRR Level 1 screening, dated 10/16/2024 conducted by an acute care hospital, reflected Resident #52 was negative for mental illness, intellectual disability, and developmental disability. The PASRR Level 1 screening also indicated that a physician certified the individual is likely to require less than 30 days of Nursing Facility services. On 02/12/2025 at 1:01 PM an interview was completed with the Director Of Nursing (DON) who stated they had been employed with the facility since January 2025. The DON stated that they were unable to provide a description of the policy for PASSAR screenings. The DON stated the importance of PASSAR screenings was to ensure that the residents have their needs met. The DON stated that a PASSAR screening should be provided before admission into the facility. The DON stated that the facility should have provided PASSAR services to a resident with a positive mental illness diagnosis. The DON stated that people outside of the facility provide PASSAR screenings. The DON stated that the DON completes a screening of the resident's documents when residents are admitted to the facility. The DON stated that a negative impact that could result from residents not receiving PASSAR services, was the residents not receiving holistic care. The DON stated she did not know the PASSAR results of Resident #16 because she was DON is new to the facility. On 02/12/2025 at 1:20PM an interview was conducted with the ADM of the facility who has been employed at the facility for 3 months. The ADM stated that the policy for PASSAR screenings was that it should be completed upon admission. The ADM stated that it was important to complete screenings because it was important to know if the resident was PASSAR positive or not. The ADM stated if a resident has a positive diagnosis of Mental illness, the facility needs to ensure that the resident should have the resources for it. The ADM stated that PASSAR screenings were completed by the MDS coordinator with the region. The ADM stated he ensures that PASSAR screenings were completed by the previous facility and if it was not provided at admission, the ADM would reach out to obtain it. The ADM stated a negative impact for the resident if PASSAR services were not provided was that the resident may not have a proper diagnosis and resources. The ADM stated a new PASSAR screening should occur after a change of condition. The ADM stated that Resident #16 had a negative PASSAR screening. The ADM denied being aware of a mental illness diagnosis. On 02/12/2025 at 02:45PM an interview was conducted with the Corporate MDS Coordinator (CMDS) who stated they had been employed with the facility since 2019. The CMDS stated that they completed audits once a month to ensure PASSAR screenings were up to date. The CMDS stated a 1012 audit had not been completed in February yet. The CMDS stated that a form 1012 should be completed and communicated with the doctor to get a new PL1, if a resident had a change of condition. The CMDS stated that if a resident had a diagnosis of Major Depressive Disorder the results should be positive. The CMDS stated that the resident should be provided with a level II PASSAR screening and notify local authorities of the results. The CMDS stated a negative outcome that could occur if a resident had a mental diagnosis but did not receive services, was the needs not being met for the resident. She stated that if a resident has a diagnosis of bipolar their PASRR should not say negative on the Level 1 screening. She stated that the facility should have reviewed the PASRR Level 1 and compared it to Resident #52's diagnoses. She stated that a negative outcome for a negative PASRR Level 1 that should have been positive and required a Level 2 screening by the LIDDA could be that the residents' needs went unmet for not receiving needed services. She stated that to ensure PASRR screenings are up to date audits were done once monthly. She stated that there has been a lot of staff turnover and that the MDS coordinator was responsible for checking these. Record Review of Resident Assessment PASSAR dated 11/2023 indicated the purpose of this policy is to ensure PASSAR's are being obtained and completed timely and accurately. This policy listed the following procedures: 1. PASSARs are obtained from referring entity by the admissions department. 2. PL 1s are put in to Simple LTC by the facility CRC within 72 hours of resident admitting to facility. The completed PL 1 must also be uploaded into the resident's EMR. 3. Communicate with LIDDA/LMHA to ensure all active positive PL 1s have a completed PE and upload the PE into the resident's EMR. 4. Review recommended Specialized Services on the PE once the PE is submitted. 5. When discharging a resident to another NF, the facility is responsible for completing a PASSARR for the NF. 6. Follow Texas PASSAR policy for all mandatory meetings and care coordination including any changes that may require a change in resident's PASSAR status.

Based on observation, interviews, and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 (Resident #12) of 8 residents who were reviewed for accuracy of assessments. The facility failed to ensure Resident #12's MDS assessment accurately reflected his hearing ability and use of hearing aids. This failure could place residents at risk of their needs going unmet. Findings included: Record review of Resident #12's quarterly MDS, dated [DATE], indicated Resident #12 was a [AGE] year-old male, who was admitted to the facility on [DATE]. He had diagnoses of dementia, major depressive disorder, depression, hereditary and idiopathic neuropathy (nervous system disorders that interfere with normal nerve function). His MDS reflected he had minimal difficulty with his ability to hear, (difficulty in some environments (e.g., when person speaks softly or setting is noisy), as well as that he did not have hearing aids or other hearing appliances. His BIMS score was 12, indicated moderately impaired cognition. Record review of Resident #12's care plan dated last revised on 01/31/2025 reflected resident had special instructions Very hard of hearing. It stated, the resident has a communication problem related to hearing loss The interventions listed included for staff to anticipate and meet needs, encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense or responds to the feeling resident is trying to express and refer to speech therapy for evaluation and treatment as ordered. Hearing aids were not care planned. Record review of Resident #12's doctor's order dated 9/24/2024 reflected, May have podiatry, dental, audiologist, & ophthalmologist consults PRN. Interview and Observation on 02/10/2025 at 10:24 a.m., revealed Resident #12 sitting in his recliner in his room watching television. The resident voiced that his hearing aids needed to be repaired and that his family member was going to come get them to be fixed/replaced. The state surveyor had to stand close, yell, speak slowly, and often repeat questions to the resident during the observation. The resident was unable to give an answer when the state surveyor asked him if the facility helps him with audiology appointments, even after writing the questions down for him due to the hearing impairment. Interview on 02/12/2025 at 10:17 a.m., with LVN C revealed she had been working remotely to help the facility since January 2025. She stated that the way she completed the MDS assessment was by looking at the social worker's assessment as well as the skilled nursing assessments in PCC, but that she did not know the residents and did not go see them before completing and signing off the MDS assessment. She stated that Resident #12 MDS should have been coded differently if the resident had hearing aids and had significant hearing impairment. Interview on 02/12/2025 at 11:40 a.m., with the DON revealed she had started working at the facility 3 weeks ago. She stated that her expectation would be that hearing aids were care planned. She stated that Resident #12 had hearing aids in his room but refused to wear them and did not like them. She said that the resident's family member had planned to take the hearing aids home with him due to the resident not wearing them. She said he reads lips very well and can sign for things he needed. She said that it should have been care planned that he did not wear them. Interview on 02/12/2025 at 12:48 p.m., with CNA A revealed she had worked at the facility for 2 years. She stated that Resident #12 would wear his hearing aids sometimes, but he had a hard time getting them to stay in his ears. She stated that she had to make sure she talked loudly and stood close to him when talking, but that most times she still had to repeat herself multiple times. She did not think he was good at reading lips due to the number of times she would have to repeat herself during conversations. Interview on 02/12/2025 at 2:00 p.m., with the CMDS revealed she had been the CMDS since 2019. She stated that when an MDS nurse was out on leave for one facility there would be another MDS nurse covering for the facility, and it was not normally the process for the MDS coordinator to work remotely and not lay eyes on the residents. She stated that the MDS nurse was responsible for ensuring MDS assessment accuracy but in this instance the covering MDS nurse should have left the assessment open for the CMDS to check for accuracy. She stated that a negative outcome for an incorrect assessment could be residents having their needs being unmet by staff. Interview on 2/12/2025 at 2:00pm, with the CMDS revealed that any inaccuracy on the MDS would be the responsibility of the MDS nurse to correct. The CMDS stated that a negative outcome for an incorrect assessment could lead to the resident receiving the wrong treatment, incorrect labs, and the plan of care not being completed as it should. She stated that her expectation was that an anticoagulant should not be included in the MDS if it was not ordered. She stated that the MDS should accurately reflect the resident's complete medical picture. Record review of the facility's Resident Assessment Instrument policy dated last revised September 2010 revealed, 3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. 4. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her practicable level of functioning. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.19.1, dated October 2024, reflected, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status. (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. 50042

Based on observation, interviews, and record review the facility failed to ensure the resident care plan accurately reflected the resident's status for 1 of 4 residents (Resident #12) who were reviewed for care plans. The facility failed to care plan Resident #12's use of hearing aids. This failure could place residents at risk of their needs going unmet. Findings included: Record review of Resident #12's quarterly MDS, dated [DATE], indicated Resident #12 was a [AGE] year-old male, who was admitted to the facility on [DATE]. He had diagnoses of dementia, major depressive disorder, depression, hereditary and idiopathic neuropathy (nervous system disorders that interfere with normal nerve function). His MDS also reflected in Section B Hearing, Speech, and Vision that Resident #12's ability to hear, had minimal difficulty, as well as that he did not have hearing aids or other hearing appliances. His BIMS score was 12, which indicated moderately impaired cognition. Record review of Resident #12's care plan dated last revised on 01/31/2025 reflected resident had special instructions Very hard of hearing. He had a focus of the resident has a communication problem related to hearing loss The interventions listed included for staff to anticipate and meet needs, encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense or responds to the feeling resident is trying to express and refer to speech therapy for evaluation and treatment as ordered. His care plan did not have any indication of hearing aid use or refusal of usage. Record review of Resident #12's doctor's order dated 9/24/2024 reflected, May have podiatry, dental, audiologist, & ophthalmologist consults PRN. Observation on 02/10/2025 at 10:24 a.m., revealed Resident #12 sitting in his recliner in his room watching television. The resident voiced that his hearing aids needed to be repaired and that his family member was going to come get them to be fixed/replaced. The hearing aids were sitting on his bedside table. The state surveyor had to stand close, yell, speak slowly, and often repeat questions to the resident during the observation. The resident was unable to give an answer when the state surveyor asked him if the facility helped him with audiology appointments, even after writing the questions down for him due to the hearing impairment. Interview on 02/12/2025 at 11:40 a.m., with the DON revealed she had started working at the facility 3 weeks ago. She stated that her expectation would be that hearing aids were care planned. She stated that Resident #12 had hearing aids in his room but refused to wear them and did not like them. She said that the resident's family member had planned to take the hearing aids home with him due to the resident not wearing them. She said he reads lips very well and can sign for things he needed. She said that it should have been care planned that he did not wear them. Interview on 02/12/2025 at 12:48 p.m., with CNA A revealed she had worked at the facility for 2 years. She stated that Resident #12 would wear his hearing aids sometimes, but he had a hard time getting them to stay in his ears. She stated that she had to make sure she talked loudly and stood close to him when talking, but that most times she still had to repeat herself multiple times. She did not think he was good at reading lips due to the number of times she would have to repeat herself during conversations. Record review of the facility's Comprehensive Care Plan policy dated last revised on 4/25/2021 revealed, Every resident will have an individualized interdisciplinary plan of care in place. The Interdisciplinary Team will continue to develop the plan in conjunction with the MDS 3.0, completing and conducting Comprehensive Care Plan Meeting and Reviews by day 21 after admission. The Interdisciplinary Team will review the healthcare practitioner's notes and orders and implement a comprehensive care plan to meet the residents' immediate care needs including but not limited to: therapy services, social services, psychosocial mood state needs as indicated, specific care plan on the main reason for admission to the community. Any updated information based on the details of the comprehensive care plan, as necessary.

Based on interviews, observations, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for two (Resident #1 and Resident #2) of ten residents reviewed for care plans. The facility failed to implement a comprehensive care plan for Resident #1 and Resident #2 with attainable interventions in place addressing the repeated facility wide known history of disputes between the two Residents. An incident occurred on 10/09/24 where video footage revealed R#1 used his cane to hit Resident #2 on the head. Resident #2 was sent to the hospital by EMS and received 10 staples to his head for a 2 cm laceration. An IJ was identified on 10/16/24. The IJ template was provided to the facility on [DATE] at 12:48 PM. While the IJ was removed on 10/18/24, the facility remained out of compliance at a scope of pattern and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. This failure placed residents at risk for not including measurable objectives and timetables to meet residents' medical, nursing, and mental and psychosocial needs to ensure resident safety. Findings included: Review of Resident #1's face sheet, dated 10/11/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included diffuse traumatic brain injury (occurs when the brain is injured by blunt force, causing the brain's nerve fibers to shear of tear (a force that acts in opposite directions, causing a tear or deformation)), depression, and heart failure. Review of Resident #1's quarterly MDS assessment, dated 08/27/24, reflected a BIMS score of 15 indicating intake cognition No information was provided in section E regarding Resident #1's behavior and did not include information about physical or verbal behaviors directed at others. On 10/10/24 at 12:20 pm observed Resident #1 ambulated using a wheelchair and he had a cane, but neither device was listed in his MDS. Review of Resident #1's quarterly care plan reflected: Focus dated 03/18/24 Resident #1 had potential to have verbal and physical aggression related to anger. Goal - the resident will demonstrate effective coping skills through the review date and the resident will not harm self or others through the review, date initiated 03/18/24, revision on 09/04/24, and target date 12/03/24 Interventions: Behavior plan in place with Resident - date initiated 03/18/24 1. Get staff to mitigate any negative encounter and remove self from confrontation with Resident #2. 2. Avoid contact with Resident #2 and not seek confrontation with Resident #2, and 3. Monitor verbal or physical aggression every shift and document observed behavior attempted in behavior log Review of Resident #1's progress note dated 03/17/24 revealed Resident #1 observed with another resident speaking harshly and using foul language, stating he was, Going to kick [Resident #2's] ass and making physical motions to indicate his intent. The nurse positioned herself in between the two residents and remained in between them at all times to prevent physical contact. Resident #1 refused to move away from Resident #2. Resident #1 repeatedly moved himself closer to Resident #2 even when asked not to and he was continuing to taunt and threaten Resident #2. Nurse removed Resident #2 from the area and brought him with her to monitor Staff was made aware of the situation and alerted to keep residents apart due to aggressive behaviors. DON and Administrator notified of situation. Review of Resident #1's progress note dated 03/18/24 reflected social worker followed up with resident to address an altercation with Resident #2 that happened over the weekend. Resident shared his version of the story. Social worker listened and provided ways to avoid altercations. Resident listened and agreed. Review of Resident #1's progress note dated 03/25/24 social worker and administrator spoke with resident regarding a conflict he had previously with Resident #2. Resident stated that he needed time space to deal with his feelings. Resident will be given time and space as requested. Social worker will follow up with Resident #1 weekly to check on him. Review of Resident #1's progress note dated 04/05/24 reflected social worker spoke with resident to follow up. Resident shared that he and another resident [Resident #2] made amends. Resident #1 stated that he forgave Resident #2 because he had to do it for himself. Review of Resident #1's progress note dated 04/05/24 reflected after dinner Resident #1 went outside behind the building and laid down on the grass. Staff attempted to talk to Resident #1 and he stated that he was going to come back inside but that he planned to stay out there until something was done to Resident #2. A call was placed to administrator and PMHNP and she recommended to call non-emergency police and see if they could talk him into coming inside. Police arrived and spoke with Resident #1 and he did come inside. The police asked the nurse what the plan was to keep him away from the man [Resident #2] Resident #1 was mad at. The plan was to place Resident #1 on every 15-minute checks to ensure he does not go near Resident #2 and smoke Resident #1 and Resident #2 away from each other. Review of Resident #1's progress note dated 08/08/24 reflected nurse went to dining room because she heard Resident #1 yelling. Upon entering the dining room Resident #1 was in his wheelchair yelling at a CNA about Resident #2. It was alleged that Resident #1 spit in the face of Resident #2. Resident #1 stated, yeah I spit on him because he [Resident #2] cusses at me. Resident was spoken to and encouraged to calm down and stop yelling and not to spit on others regardless of their activity, PMHNP, DON, and Administrator notified. Review of Resident #1's progress note dated 08/24/24 reflected Resident #1 was returned to facility by the police, police said they found him across the street where he called 911. Nurse asked resident what happened, and Resident #1 said he had called 911 because he was tired of having Resident #2, feeling like he can say anything he wants to me and I won't take it anymore so I went across the street and called the police on my phone. Nurse assured resident that measures have been taken to resolve this situation and will continue plan of care. Review of Resident #1's progress note dated 09/04/24 reflected CNA informed the nurse of an altercation between Resident #1 and Resident #2 in which Resident #2 kicked Resident #1's wheelchair and Resident #1 hit Resident #2 on the knee with his cane. Review of Resident #1's progress note dated 09/23/24 reflected resident was seen by PMHNP by virtual visit. R had had incident where he was kicked and hit by Resident #2 and he hit Resident #2 with his cane. Both residents had to be separated and were taken to their rooms. PMHNP discussed the incident with Resident #1 and he stated facility staff seem to be keeping Resident #2 away from him so Resident #1 felt safe. Resident #1 said that he felt if the facility staff let him [Resident #2] loose Resident #2 would go back to being himself. Resident #1 said Resident #2 hit him five times, cursed at him 10 times, and shot the finger at him until he had no choice but to result to violence. The note reflected the DON was told about the conversation and the DON agreed to put a plan in place to help Resident #1 feel safe and to prevent further incidents. Review of Resident #1's progress note dated 09/23/24 reflected nurse spoke with Resident #1 regarding issues he was having with Resident #2. Resident #1 stated he is not going to seek out Resident #2 and initiate behaviors, however, if Resident #2 provokes him he intends to finish it. Resident #1as asked what he meant by this statement and Resident #1 stated that if Resident #2 provoked him he would, get him back. The nurse, DON, who wrote the progress note stated she also spoke with the PMHNP to initiate a behavioral care plan at this time and contacted the ombudsman for assistance in developing a behavior plan. Review of Resident #1's progress note dated 10/09/24 reflected Resident #1 was assessed because of an altercation with Resident #2. Resident #1 stated that he had been hit in the face by Resident #2. Resident #1 assessed and found with no visible injury related to the incident. Note reflected there is a 2X1 (unit of measure not noted)) slightly reddened area noted to the left side of residents left eye. Resident stated that Resident #2 hit him in the face and he hit Resident #2 with his cane on the top of Resident #2's head. Resident #1 stated that the reddened area did not hurt and he wasn't sure if that was related to the incident. Review of Resident #1's progress note dated 10/10/24 reflected social worker followed up with Resident #1 and discussed his feelings. Request for placement was made to various nursing facilities, but placement for Resident #1 was declined by facilities due to Resident #1's aggressive behavior. He was accepted to a group home. Review of Resident #1's initial assessment visit on 04/03/24 with PMHNP reflected Resident #1 admitted to mental health conditions, depression and stated someone had insulted him three times (resident not identified). Anxiety: Patient endorsed current symptoms of excessive worry and denies symptoms of restlessness, irritability/agitation, impaired concentration, panic attacks and anticipatory worry/impending doom. Severity level is 2 (Minimal). Review of Resident #1's visit on 05/15/24 with PMHNP reflected Resident admitted to being mad. He stated I was assaulted 4xs [by Resident #2] and, they are still bringing him [Resident #2] around me and right now I'm after him [Resident #2]. Resident #1 stated if he's not around [Resident #2] I'm happy. Review of Resident #1's visit on 05/20/24 with PMHNP reflected Resident #1, Admits to being agitated due to feeling he has been disrespected by another resident [Resident #2]. Received call from facility the past weekend due to resident going outside and refusing to come back in due to not wanting to be around resident [Resident #2] he feels he was disrespected by. Review of Resident #1's visit on 07/31/24 with PMHNP reflected, staff reports resident made a [shank] out of foil and is carrying a cane as a weapon. Patient endorses current symptoms of excessive worry, irritability/agitation and impaired concentration and admits to anxiety and agitation due to, wanting a cane. Review of Resident #1's visit on 08/13/24 with PMHNP reflected, staff reports that patient had an incident where he left the facility and went to a park to look for a stick. Review of Resident #1's visit on 08/25/24 with PMHNP reflected Resident #1 stated he did well as long as another resident [Resident #2] that he has had incidents with stayed away from him and, Resident #1, Becomes agitated when he sees the resident [Resident #2] that he has problems with. Review of Resident #1's visit on 10/06/24 with PMHNP reflected reason for referral anger, physical aggression. Review of Resident #1's visit on 10/09/24 with PMHNP reflected reason for referral, Anger, physical aggression. Patient seen today for a new problem. At staff request for continued unstable symptoms that have showed limited improvement. PMHNP visit reflected Resident #1 was seen for a follow up visit due to behaviors that lead to an altercation with another resident [Resident #2]. When asked about the altercation he stated that it was the sixth time he has [Resident #2] hit me or kicked me, in the past he, brought blood on me. I was going to the smoke area, and he was in the way, and I pulled Resident #2's chair and told him he was not supposed to go out there. I was tired of going and getting someone, so I held him back this time and told him you are not going out there you are not supposed to be out there. They want me to get someone every time he goes out there, he said I was here first and that is when he hit me and I hit him back. He thinks he can hit people and cuss them with no recourse. The visit reflected that the PMHNP asked him when you see Resident #2 does that make you angry and Resident #1 responded, yes because every time he comes around I have to watch him. A few days ago he kicked at me, but I didn't notify anyone. He is constantly shooting the finger and cussing me. When asked if he was aware that the resident went to the emergency room with a head injury Resident #2 stated, well, he hit me first and between me and you I am tired and fed up with him so I hit him. Resident #1 said he was anxious when he was around Resident #2 and the facility staff knew he [Resident #2] was mean and cruel, vial and violent. Resident #2 expected everyone to move out of his way and kept getting by with it and, that is the reason he keeps doing it. It's on my mind and I can't forget what hes done to me. I can't stand to be around him. We used to get along he was banned from the smoking area in the past I tried to get him and help him and he still hit me and I don't want to be around him period. Review of Resident #1's visit on 10/01/24 with MSW, LCSW reflected service provided, new referral, reason for referral anger, physical aggression. Patient [Resident #1] described an altercation between him and another resident [Resident #2]. Review of Resident #1's visit on 10/08/24 with MSW, LCSW reflected current risk factors, Aggressive Behavior: Current and History, Mental Status Examination Affect: Angry, Anxious, Agitated. Review of Resident #2's face sheet, dated 10/11/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, bipolar type (which features bouts of mania and sometimes depression), and diffuse trauma brain injury (occurs when the brain is injured by blunt force, causing the brain's nerve fibers to shear of tear). Review of Resident #2's quarterly MDS assessment, dated 08/27/24, reflected a BIMS score of 14 indicating intact cognition. No information was provided in section E regarding potential indicators of Psychosis. No information was provided in section E regarding Resident #1's behaviors, physical or verbal, directed at others or other behavioral symptoms not directed toward others (e.g., hitting or scratching self). On 10/10/24 at 4:18 pm observed Resident #2 in a wheelchair. No wheelchair was listed in his MDS. Review of Resident #2's quarterly care plan reflected: Focus: 1. Resident #2 had behavior problems as a result of schizoaffective disorder - yelling, racial slurs, name calling 2. 09/04/24 aggressive behaviors date initiated 12/15/23 revision on 09/05/24 Goals: 1. Resident #2 will have less than daily behaviors hitting self. Impulsiveness, racial slurs by review date Date initialed 12/15/23, revision date 03/04/24, and target date 12/09/24 Interventions: 1. administer medication as ordered, monitor/document for side effects and effectiveness date initialed 12/15/23 2. anticipate and meet the resident's needs dated initiated 12/15/23 3. Behavior plan in place: 1. Resident #2 will smoke in separate smoking area from Resident #1 and will be provided supervision on that break Resident #1 will avoid contact with Resident #2 and if they meet in person, Resident #1 will not say provoking things to Resident #2 or have physical altercation. Resident will alert staff if he feels unsafe or if he feels unsafe or if Resident #2 threatens him for immediate interventions date initiated 09/23/24 2. document any behaviors and interventions in clinical record as they occur date initiated 01/26/24 3. medication review by psych date initiated 02/15/24 4. monitor behavior episodes and attempt to determine underlying causes, consider location, time of day, persons involved, and situation and document behavior and potential causes date initiated 12/15/23 5. Weekly discussion regarding social services date initiated 01/26/24 Review of Resident #2's progress note dated 09/04/24 6:23 PM reflected ambulance arrived at the facility and stated that they were called by resident #2. The nurse asked the resident why he called and Resident #2 stated he got into an altercation with Resident #1 in the smoking area and his right knee hurt. Assessment of knee revealed no wound, no bleeding or inflammation noted to the knee. Resident #2 insisted on being sent out and stated, if you don't let me go I'll cause hell to everyone here. The responsible party, ADON, DON, medical director, and Administrator were informed. Note reflected, will continue plan of care. Review of Resident #2's progress note dated 09/04/24 7:36 PM reflected police officer arrived at the facility and insisted on speaking to Resident #1 because of a report an altercation between him and Resident #2. Resident #2 called the police. There were no staff present when the altercation occurred. Review of Resident #2's progress note dated 09/11/24 reflected Resident #2 continued 1 on 1 monitoring (reason for 1 on 1 monitoring not explained in note). Review of Resident #2's progress note dated 09/23/24 6:00 PM reflected resident seen for follow up virtual visit with PMHNP, Resident #2 was placed 1 on 1 due to having multiple on/off behaviors of aggression/ agitation with other residents. Medication had been adjusted over the last two weeks. He currently denies being a harm to himself or others. Staff reports that he has not had any noted agitation/aggression with him during one-to-one period and he denied harm to himself or others. Will discontinue 1 on 1 at this time and follow up with resident with face-to-face visit within one week. Review of Resident #2's progress note dated 09/23/24 8:00 PM reflected nurse spoke with resident regarding issues he was having with Resident #1. Resident #2 stated that he felt safe at this time and will do his best to stay away from Resident #1, the resident with whom he was having trouble with. The nurse spoke with the PMHNP regarding the safety of Resident #2 and she stated she had completed an assessment of him and the situation and in her opinion Resident #2 was not a danger to himself or others at this time. The facility was to provide a separate smoking areas Resident #1 and Resident #2 and to keep them separated as much as possible. The note reflected a discussion with the PMHNP to initiate a behavioral care plan and contact with the ombudsman for assistance in developing a behavior plan. Review of Resident #2's progress note dated 10/09/24 by LVN A reflected she heard someone yelling and went into the sunroom and noticed Resident #1 sitting behind resident #2. Resident #1 had his cane raised in the air. Resident #2 was leaning over and he had blood dripping from the top of his head. A second nurse (not identified in the note) went to get the DON, Administrator, and called 911. When the LVN A walked into the sunroom Resident #1 said Resident #2 hit him in the face and he hit Resident #2 on his head with his cane. Resident #2 stated Resident #1 called him a son of a bitch and told him not to talk about his mother. Resident #1 stated Resident #2 hit him in the face, and he hit Resident #2 with his cane. The police came and talked to Resident #2. Review of Resident #2's visit on 01/10/24 with PMHNP reflected reason for referral issues with trauma. Mania: Resident #2 endorsed current symptoms of grandiosity and easily distracted. Anxiety: Resident #2 endorsed symptoms of excessive worry, irritability/agitation and anticipatory worry/impeding doom. Cognitive impairment: Resident #2 endorsed current symptoms of forgetfulness, confusion, mood/personality change and difficulties with activities of daily living. Review of Resident #2's visit on 01/24/24 with PMHNP reflected Mania: Resident #2 endorsed current symptoms of grandiosity and easily distracted. Review of Resident #2's visit on 02/06/24 with PMHNP reflected Mania: Resident #2 endorsed current symptoms of grandiosity and easily distracted and hyper-focused behavior. Review of Resident #2's visit on 02/28/24 with PMHNP reflected Mania: Resident #2 endorsed current symptoms of grandiosity and easily distracted, impulsive actions and hyper-focused behavior. Resident #2 endorsed symptoms of decreased concentration. MSE mood - anxious, depressed. Review of Resident #2's visit on 03/10/24 with PMHNP reflected Mania: Resident #2 endorsed current symptoms of grandiosity, impulsive actions and hyper-focused behavior, and history of easily distracted. MSE mood - anxious, depressed. Review of Resident #2's visit on 04/03/24 with PMHNP reflected Mania: Resident #2 endorsed current symptoms of grandiosity, easily distracted and impulsive actions. Anxiety: resident #2 endorsed current symptoms of excess worry and irritability/agitation. MSE anxious, depressed, short-term memory mildly impaired. Review of Resident #2's visit on 04/08/24 with PMHNP reflected Mania: Resident #2 endorsed current symptoms of grandiosity, pressured speech/hyper-verbosity and easily distracted. Psychosis: Resident #2 endorsed current symptoms of delusions. He reports that another resident threw a 20oz. Coke at him and he responded by hitting her back. Resident #2 admitted to feeling own and depressed and being anxious. He denied being a harm to himself or anyone else. Resident #2 endorsed current symptoms of sad moods and decreased concentration. Review of Resident #2's visit on 04/24/24 with PMHNP reflected Mania: Resident #2 endorsed current symptoms of grandiosity, pressured speech/hyper-verbosity and easily distracted. Psychosis: Resident #2 endorses current symptoms of delusions. Review of Resident #2's visit on 05/07/24 with PMHNP reflected Resident #2 endorsed current symptoms of decreased concentration. Mania: Resident #2 endorsed current symptoms of grandiosity, pressured speech/hyper-verbosity and easily distracted. Anxiety: Resident #2 endorsed current symptom of impaired concentration. Cognitive Impairment: Resident #2 endorsed current symptoms of mood/personality change. Psychosis: Resident #2 endorsed current symptoms of delusions. MSE: Mood anxious, depressed, short-term memory mildly impaired. Review of Resident #2's visit on 05/20/24 with PMHNP reflected Resident #2 endorsed current symptom of decreased concentration. Manie: Resident #2 endorsed current symptom of grandiosity, pressured speech/hyper-verbosity and easily distracted. Anxiety: Resident #2 endorsed current symptoms of impaired concentration. Cognitive impairment: Resident #2 endorsed current symptom of mood/personality change. Psychosis: Resident #2 endorsed current symptoms of delusions and responding to internal stimuli. MSE: Mood anxious, depressed, short-term memory mildly impaired. Review of Resident #2's visit on 06/02/24 with PMHNP reflected Resident #2 endorsed current symptoms of decreased concentration. Mania: Resident #2 endorsed symptoms of grandiosity and easily distracted. Cognitive impairment: Resident #2 endorsed current symptoms of forgetfulness mood/personality change. Psychosis: Resident #2 endorsed symptoms of delusions. MSE: Mood anxious, depressed, short-term memory mildly impaired. Review of Resident #2's visit on 01/24/24 with MSW, LCSW reflected Resident #2 was referred due to his anger outbursts and inappropriate remarks such as racial slurs. Brief psychiatric rating scale reflected BPRS current ratings: Disorientation - moderately severe Grandiosity - moderately severe Review of Resident #2's visit on 02/14/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, behavior, conduct problems, depression, anxiety, and confusion Review of Resident #2's visit on 02/20/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, behavior, conduct problems, depression, anxiety, and confusion Review of Resident #2's visit on 02/28/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, behavior, conduct problems, depression, anxiety, and confusion Review of Resident #2's visit on 03/05/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, behavior, conduct problems, depression, anxiety, and confusion Review of Resident #2's visit on 03/12/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, behavior, conduct problems, depression, anxiety, and confusion Review of Resident #2's visit on 03/20/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, behavior, conduct problems, depression, anxiety, and confusion Resident #2 discussed the incident that happened over the weekend and he processed his feeling for anger. Review of Resident #2's visit on 03/25/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, behavior, conduct problems, depression, anxiety, and confusion Review of Resident #2's visit on 04/02/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, behavior, conduct problems, depression, anxiety, and confusion Review of Resident #2's visit on 04/23/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, depression, anxiety, and confusion Resident #2 seemed to be having difficulty managing emptions and longed to be discharged and reside with family. Review of Resident #2's visit on 04/30/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, depression, anxiety, and confusion Review of Resident #2's visit on 05/08/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, depression, anxiety, and confusion Review of Resident #2's visit on 05/14/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, depression, anxiety, and confusion Resident #2 discussed the incident he had with, another staff. He processed his feelings of anger. Resident #2 noted how he could have handled things, differently. He listed triggers that made him angry. Review of Resident #2's visit on 05/21/24 with MSW, LCSW reflected history of current illness: Resident #2 was referred due to his anger outbursts and inappropriate remarks, such as racial slurs. Grandiosity moderately severe no change, hostility moderate - increase, and excitement - increase. Review of Resident #2's visit on 05/28/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Review of Resident #2's visit on 06/06/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Resident #2 reported feelings of anger when speaking about the incident that happened. Review of Resident #2's visit on 06/12/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe On 10/11/24 at 12:30 observed Resident #1 ambulating using a wheelchair and had a cane with him. On 10/11/24 at 4:18 pm observed Resident #2 in a wheelchair. Interview on 10/11/24 at 1:04 pm with CNA B revealed as far as she knew, Resident #1 and Resident #2 did not get along. Resident #2 called Resident #1 white trailer trash and Resident #1 did not let that go. CNA B said she observed Resident #1 and Resident #2 argue and they were separated. Resident #1 was on 1 on 1 because of an altercation with Resident #2. CNA B said when Resident #1 saw Resident #2, Resident #1 was on the defense. Staff were all supposed to keep on eye on Resident #1 and Resident #2. Sometimes Resident #2 would come into the group smoking area and Resident #1 would get upset and tell Resident #2 he could not be in that smoking area. CNA B said because of Resident #2's brain injury, she was not sure if he understood he could not be in the community smoking area. CNA B said Resident #2 did not verbalize that he knew that he was not supposed to be in the community smoking area, and he did not do one half of the stuff he was told. Intervi [TRUNCATED]

Based on interviews, observations, and record review, the facility failed to protect Resident #2's right to be free from physical, mental, and verbal abuse by Resident #1. The facility failed to protect Resident #1 from abuse by Resident #2. Residents had an established and repeated facility wide known history of disputes, both verbal and attempted physical alterations. On 10/09/2024, both residents were in the same room unattended by staff and video footage revealed Resident #1 used his cane to hit Resident #2 on the head. Resident #2 was sent to the hospital by EMS and received 10 staples to his head for a 2 cm laceration. An IJ was identified on 10/12/24. The IJ template was provided to the facility on [DATE] at 1:45 PM. While the IJ was removed on 10/18/24, the facility remained out of compliance at a scope of pattern and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. This failure placed residents at risk for abuse, injuries, and pain. Findings included: Review of Resident #1's face sheet, dated 10/11/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included diffuse traumatic brain injury (occurs when the brain is injured by blunt force, causing the brain's nerve fibers to shear of tear), depression and heart failure. Review of Resident #1's quarterly MDS assessment, dated 08/27/24, reflected a BIMS score of 15 indicating intake cognition. On 10/11/24 at 12:30 pm observed Resident #1 ambulating using a wheelchair and had a cane with him, but neither device was listed in his MDS. Review of Resident #1's quarterly care plan reflected: Focus dated 03/18/24 Resident #1 had potential to have verbal and physical aggression related to anger. Goal - the resident will demonstrate effective coping skills through the review date and the resident will not harm self or others through the review, date initiated 03/18/24, revision on 09/04/24, and target date 12/03/24. Interventions: Behavior plan in place with Resident - date initiated 03/18/24 4. Get staff to mitigate any negative encounter and remove self from confrontation with Resident #2. 5. Avoid contact with Resident #2 and not seek confrontation with Resident #2, and 6. Monitor verbal or physical aggression every shift and document observed behavior attempted in behavior log On 10/11/24 at 12:30 pm observed Resident #1 ambulating using a wheelchair and had a cane with him, but neither device was listed in his care plan. Review of Resident #2's face sheet, dated 10/11/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, bipolar type (which features bouts of mania and sometimes depression), and diffuse trauma brain injury (occurs when the brain is injured by blunt force, causing the brain's nerve fibers to shear of tear). Review of Resident #2's quarterly MDS assessment, dated 08/27/24, reflected a BIMS score of 14 indicating intact cognition. On 10/10/2024 at 4:18 pm observed Resident #2 in a wheelchair but this was not listed in his MDS. Review of Resident #2s quarterly care plan reflected: Focus: 3. Resident #2 had behavior problems as a result of schizoaffective disorder - yelling, racial slurs, name calling 4. 09/04/24 aggressive behaviors date initiated 12/15/23 revision on 09/05/24 Goals: 2. Resident #2 will have less than daily behaviors hitting self. Impulsiveness, racial slurs by review date Date initialed 12/15/23, revision date 03/04/24, and target date 12/09/24 Interventions: 4. administer medication as ordered, monitor/document for side effects and effectiveness date initialed 12/15/23 5. anticipate and meet the resident's needs dated initiated 12/15/23 6. Behavior plan in place: 6. Resident #2 will smoke in separate smoking area from Resident #1 and will be provided supervision on that break 7. Resident #1 will avoid contact with Resident #2 and if they meet in person, Resident #1 will not say provoking things to Resident #2 or have physical altercation. Resident will alert staff if he feels unsafe or if he feels unsafe or if Resident #2 threatens him for immediate interventions date initiated 09/23/24 8. document any behaviors and interventions in clinical record as they occur date initiated 01/26/24 9. medication review by psych date initiated 02/15/24 10. monitor behavior episodes and attempt to determine underlying causes, consider location, time of day, persons involved, and situation and document behavior and potential causes date initiated 12/15/23 11. Weekly discussion regarding social services date initiated 01/26/24 On 10/10/24 at 4:18 pm observed Resident #2 in a wheelchair, but this was not listed in his care plan. Resident #1 Review of Resident #1's progress note dated 03/17/24 revealed Resident #1 observed with another resident speaking harshly and using foul language, stating he was, Going to kick [Resident #2's] ass and making physical motions to indicate his intent. The nurse positioned herself in between the two residents and remained in between them at all times to prevent physical contact. Resident #1 refused to move away from Resident #2. Resident #1 repeatedly moved himself closer to Resident #2 even when asked not to and he was continuing to taunt and threaten Resident #1. Nurse removed Resident #2 from the area and brought him with her to monitor Staff was made aware of the situation and alerted to keep residents apart due to aggressive behaviors. DON and Administrator notified of situation. Review of Resident #1's progress note dated 04/05/24 reflected after dinner Resident #1 went outside behind the building and laid down on the grass. Staff attempted to talk to Resident #1, and he stated that he was going to come back inside but that he planned to stay out there until something was done to Resident #2. A call was placed to administrator and PMHNP and she recommended to call non-emergency police and see if they could talk him into coming inside. Police arrived and spoke with Resident #1, and he did come inside. The police asked the nurse what the plan was to keep him away from the man [Resident #2] Resident #1 was mad at. The plan was to place Resident #1 on every 15-minute checks to ensure he does not go near Resident #2 and smoke Resident #1 and Resident #2 away from each other. Review of Resident #1's progress note dated 08/08/24 reflected nurse went to dining room due to hear Resident #1 yelling. Upon entering the dining room Resident #1 was in his wheelchair yelling at a CNA about Resident #2. It was alleged that Resident #1 spit in the face of Resident #2. Resident #1 stated, yeah I spit on him because he [Resident #2] cusses at me. Resident was spoken to and encouraged to calm down and stop yelling and not to spit on others regardless of their activity. PMHNP, DON, and Administrator notified. Review of Resident #1's progress note dated 08/24/24 reflected Resident #1 was returned to facility by the police, police said they found him across the street where he called 911. Nurse asked resident what happened, and Resident #1 said he had called 911 because he was tired of having Resident #2, feeling like he can say anything he wants to me and I won't take it anymore so I went across the street and called the police on my phone. Nurse assured resident that measures have been taken to resolve this situation and will continue plan of care. Review of Resident #1's progress note dated 09/04/24 reflected CNA informed the nurse of an altercation between Resident #1 and Resident #2 in which Resident #2 kicked Resident #1's wheelchair and Resident #1 hit Resident #2 on the knee with his cane. Review of Resident #1's progress note dated 09/23/24 reflected nurse spoke with Resident #1 regarding issues he was having with Resident #2. Resident #1 stated he is not going to seek out Resident #2 and initiate behaviors, however, if Resident #2 provoked him he intended to finish it. Resident #1 was asked what he meant by this statement and Resident #1 stated that if Resident #2 provoked him he would, get him back. The nurse, who was the done DON, who wrote the progress note stated she also spoke with the PMHNP to initiate a behavioral care plan and contacted the ombudsman for assistance in developing a behavior plan. Review of Resident #1's progress note dated 10/09/24 reflected Resident #1 was assessed because of an altercation with Resident #2. Resident #1 stated that he had been hit in the face by Resident #2. Resident #1 assessed and found with no visible injury related to the incident. Note reflected there is a 2X1 (unit of measure not noted) slightly reddened area noted to the left side of residents left eye. Resident stated that Resident #2 hit him in the face, and he hit Resident #2 with his cane on the top of Resident #2's head. Resident #1 stated that the reddened area does not hurt, and he wasn't sure if that was related to the incident. Resident #2 Review of Resident #2's progress note dated 09/04/24 6:23 PM reflected ambulance arrived at the facility and stated that they were called by resident #2. The nurse asked the resident why he called the ambulance and Resident #2 stated he got into an altercation with Resident #1 in the smoking area and his right knee hurt. Assessment of knee revealed no wound, no bleeding, or inflammation noted to the knee. Resident #2 insisted on being sent out and stated, if you don't let me go I'll cause hell to everyone here. The responsible party, ADON, DON, medical director, and Administrator were informed. Note reflected, will continue plan of care. Review of Resident #2's progress note dated 09/04/24 7:36 PM reflected police officer arrived at the facility and insisted on speaking to Resident #1 because of a report an altercation between him and Resident #2. Resident #2 called the police. There were no staff present when the altercation occurred. Review of Resident #2's progress note dated 09/11/24 reflected Resident #2 continued 1 on 1 monitoring (reason for 1 on 1 monitoring not explained in note). Review of Resident #2's progress note dated 09/23/24 6:00 PM reflected resident seen for follow up virtual visit with PMHNP, Resident #2 was placed 1 on 1 due to having multiple on/off behaviors of aggression/ agitation with other residents. Medication had been adjusted over the last two weeks. Resident #2 currently denies being a harm to himself or others. Staff reported that he has not had any noted agitation/aggression with him during one-to-one period and he denied harm to himself or others. Will discontinue 1 on 1 at this time and follow up with resident with face-to-face visit within one week. Review of Resident #2's progress note dated 09/23/24 8:00 PM reflected nurse spoke with resident regarding issues he was having with Resident #1. Resident #2 stated that he felt safe at this time and will do his best to stay away from Resident #1, the resident with whom he was having trouble with. The nurse spoke with the PMHNP regarding the safety of Resident #2 and she stated she had completed an assessment of him and the situation and in her opinion Resident #2 was not a danger to himself or others at this time. The facility was to provide a separate smoking areas Resident #1 and Resident #2 and to keep them separated as much as possible. The note reflected a discussion with the PMHNP to initiate a behavioral care plan and contact with the ombudsman for assistance in developing a behavior plan. Review of Resident #2's progress note dated 10/09/24 by LVN A reflected she heard someone yelling and went into the sunroom and noticed Resident #1 sitting behind resident #2. Resident #1 had his cane raised in the air. Resident #2 was leaning over and he had blood dripping from the top of his head. A second nurse (not identified in the note) went to get the DON, Administrator, and called 911. When the LVN A walked into the sunroom Resident #1 said Resident #2 hit him in the face and he hit Resident #2 on his head with his cane. Resident #2 stated Resident #1 called him a son of a bitch and told him not to talk about his mother. Resident #1 stated Resident #2 hit him in the face, and he hit Resident #2 with his cane. The police came and talked to Resident #2. Review of police report dated 10/09/24 reflected the DON advised the officer that Resident #1 and Resident #2 got into an altercation. DON stated that she was unaware of how the situation started but advised that Resident #1 and Resident #2 had several instances of verbal altercations and stated that they didn't like each other. Resident #2 had an open laceration on his head that was being treated. Resident #2 stated he and Resident #1 were in the sunroom by the smoking area when the incident occurred. Resident #2 said Resident #1 called him a son of a bitch which then caused him to punch Resident #1 using his right arm with a closed fist in the nose. The officer asked Resident #2 how hard he tried to punch Resident #1 and he said, As hard as he could. Resident #2 then stated that's when Resident #2 used his walking cane to hit him in the head, causing the open laceration. The officer observed the laceration on Resident #2's head. Resident #2 was transported to the hospital. The officer contacted the Administrator who provided him with camera footage of the incident. In the camera footage, the officer observed Resident #1 and Resident #2 in the sunroom by the smoking area. The officer observed that Resident #2 blocked the doorway path, trying to prevent Resident #1 from going to the smoking area. Resident #1 pulled on Resident #2's wheelchair, trying to pull him away from the door, and Resident #1 threw a closed fisted punch (unsure if it connected with Resident #2), to which Resident #1 retaliated by hitting Resident #1 on the head with his walking cane. Resident #1 was asked to give his side of the story and he said Resident #2 wasn't supposed to be in that particular smoking area and Resident #1 was trying to get Resident #2 to leave by pulling on his wheelchair. Resident #1 stated they exchanged words and then got hit by Resident #2 under his left eye, which then caused him to hit Resident #2 with his cane. The officer then asked how hard he tried to hit Resident #1 and Resident #2 responded, saying, Well, it was enough to make him bleed. The officer observed redness under Resident #1's left eye. In an interview on 10/11/24 at 12:30 pm with Resident #1, he revealed the issues with Resident #2 had been ongoing for a while and Resident #2 had hit and kicked him several times. Resident #2 said he told Resident #1 he would knock him in the head if he did it again and that is what he did. Resident #1 said he warned Resident #2 a couple of days earlier and Resident #1 had been to the Administrator's office thirteen times and said that if Resident #2 hit him, he was going to hit Resident #2. Resident #1 said that Resident #2 was not supposed to be in the smoking area, and he told Resident #2 you are not supposed to be in the smoking area and Resident #2 hit across his face so Resident #2 knocked him in the head with his cane. In an interview on 10/11/24 at 4:18 pm with Resident #2, he revealed Resident #2 hit him over the head with a cane and it made him bleed. Interview on 10/11/24 at 1:04 pm, CNA B who revealed as far as she knew, Resident #1 and Resident #2 did not get along. Resident #2 called Resident #1 white trailer trash and Resident #1 did not let that go. CNA B said she observed Resident #1 and Resident #2 argue and they were separated. Resident #1 was on 1 on 1 because of an altercation with Resident #2. CNA B said when Resident #1 saw Resident #2, Resident #1 was on the defense. Staff were all supposed to keep an eye on Resident #1 and Resident #2. Sometimes Resident #2 would come into the group smoking area and Resident #1 would get upset and tell Resident #2 he could not be in that smoking area. CNA B said because of Resident #2's brain injury she was not sure if he understood he could not be in the community smoking area. CNA B said Resident #2 did not verbalize that he knew that he was not supposed to be in the community smoking area, and he did not 1/2 of the stuff he was told. Interview on 10/11/24 at 2:27 pm with CNA C revealed staff told Resident #2 multiple times he could not be in the same area with Resident #1 because they always, bumped heads. Resident #2 was supposed to smoke on another hallway, but he insisted, everyday on going to the other hallway to smoke. CNA revealed Resident #2 went over to the community smoking area 15 or thirty minutes before the smoking time began. CNA C revealed Resident #2 went where he wanted to go and would say things to antagonize other people. Interview on 10/11/23 at 3:05 pm with CNA D revealed Resident #1 and Resident #2 should not have been alone and the Administrator did not want them to cross paths. Resident #1 was an aggressor and he and Resident #2 should not have been in a space together, alone, without supervision. Resident #2 would try to enter the community smoking area and she would tell Resident #2 you cannot be in this smoking area, and I will take you to smoke when I am finished here. CNA D revealed this happened several times a week. She said she reported this to the DON and ADON. She said she told the ADON and the DON it would be best if someone took Resident #2 out when she took the others out. If Resident #2 came out to the community smoking area, Resident #1 would cuss at Resident #2 and tell him you are not supposed to be out here and you are not allowed to be around me. Resident #2 could be on the complete opposite side of the building but if Resident #1 saw Resident #2, Resident #1, would see red. Interview on 10/11/24 at 4:59 pm with the ADON revealed they did their best to keep Resident #1 and Resident #2 apart. They were assigned separate smoking and eating areas. Resident #2 would go wherever he really wanted to go. There was a staff in-service that instructed that Resident #1 and Resident #2 should be kept separated. Resident #1 made it very clear he did not like Resident #2. The ADON said there was concern about them getting into an altercation, but she felt like the staff was keeping them separated. Interview on 10/11/24 at 12:30 pm DON who revealed Resident #1 and Resident #2 were in an altercation in the sunroom. Resident #1 came up behind Resident #2 and grabbed Resident #2's wheelchair and tried to pull Resident #2 away from the smoking area door. The video of the incident has no audio. Resident #1 hit Resident #2 over the head with his cane. There was no staff member present. There was a plan in place where Resident #2 was not supposed to be smoking at the same time as Resident #1. The residents were not supposed to be together. The staff had been in-serviced on keeping Resident #1 and Resident #2 separated, and it was care planned for each resident. The staff was aware of the residents' poor relationship. The residents were not on 1 to 1 supervision. The Residents had previous verbal altercations and one previous physical altercation. The DON thought the men did not like each other. Both men had a diagnosis of traumatic brain injury. Resident #2 received a significant injury to his head, a 2 cm laceration, when he was hit by Resident #1 with Resident #1's cane. The DON said Resident #2 could be impulsive. Review of the facility's abuse and neglect policy, undated 01/01/23, reflected: The purpose of this policy is to ensure that each resident has the right to be free from any type of abuse The facility staff will adhere to the policies and procedures and will follow the guidelines in the written policy and procedure. The facility administrator is the appointed abuse coordinator and in his/her absence a designee with be appointed. Abuse is willful infliction of injury or negligent, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident. Resident will not be subjected to abuse by anyone including but not limited to community staff, other residents The administrator and or designee are responsible for maintaining all facility policies that prohibit abuse, neglect, and misappropriation of funds/personal belongings. In the event of a resident-to-resident abuse, the facility will immediately protect the resident being abused and all other residents in the facility. If the initial determination is that the perpetrator is a threat to the health and safety of the residents in the facility as determined by the attending physician/or other physician, the resident will be discharged as soon as possible. During the time that the perpetrator has not been discharged , the facility will monitor this resident one-on-one to protect all other residents. The ADM was notified on 10/12/24 at 1:45 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 10/17/24 at 4:05 PM: Plan of Removal On 10/12/2024 the surveyor provided an Immediate Jeopardy template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to the resident health and safety. Removal of Immediacy Plan PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY Impact Statement Abuse The resident has the right to be free from abuse, neglect misappropriation of resident property as defined in this subpart. This includes but is not limited to freedom from corporal punishment involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Identify residents who could be affected All residents who came into contact with Resident #1 had the potential to be affected by this alleged deficient practice. All residents who come into contact with resident #2 has the potential to be affected by this alleged deficient practice. Problem The facility failed to keep the residents free from abuse. Action Taken Resident #1 was placed on 1:1 and remained 1:1 until discharge. Resident #2 was placed on 1:1 until cleared by Psychology Nurse Practitioner. Administrator and Director of Nursing were in-serviced by Regional [NAME] President of Operations on 10-12-2024 to include keeping resident within eyesight at all times and maintaining resident safety. Staff members assigned to 1:1 will be in-serviced by Director of Nursing and/or designee on responsibilities to include keeping resident within eyesight at all times and maintaining resident safety. This in-service will occur prior to the start of each 1:1 shift. This will continue while resident remains 1:1. The administrator will oversee actions taken. Safe Surveys were conducted by administrative nurses/designee with alert and oriented residents to determine if there were any residents who did not feel safe in the facility. Safe survey did not reveal any additional resident that cause fear or abuse. Verification of completion on 10-12-2024 was done by the Administrator. For those non-alert and non-oriented residents all nurses have been educated on 10-13-24 to monitor for changes in behavior and skin during weekly skin assessments for non-verbal signs and symptoms of abuse this will continue indefinitely. All new nurses will be trained during orientation. The Director of Nursing and/or designee began educating all staff on the facility's Abuse and Neglect policy on 10-12-2024. All staff will be educated prior to their next assigned shift. Training will continue until all staff have been educated by 10-13-2024. All new staff will be trained during orientation. Agency staff are not used in the facility. The Director of Nursing and/or designee began educating all clinical staff on following resident #2 plan of care on 10-12-2024. All clinical staff will be educated prior to their next assigned shift. Training will continue until all clinical staff have been educated by 10-13-2024. All new clinical staff will be trained during orientation. Agency staff are not used in the facility. Involvement of Medical Director and Quality Assurance Ad HOC QA meeting held with the medical director on 10-12-2024 to review all aspects of Immediate Jeopardy and Initial Plan of removal. QA meetings are held on a monthly basis and all allegations, incidents, and accidents will be reviewed during the QA meeting. The next QA meeting will be 11-12-2024. This will be an ongoing process. Monitoring: Reviewed facility documentation that Resident #1 was placed on 1:1 and remained 1:1 until he was discharged from the facility on 10/11/24. Reviewed documents that Resident #2 was placed on 1:1 until cleared by Psychology Nurse Practitioner. Resident #2 1:1 monitoring still continued at time of investigator exit. Reviewed facility Safe Surveys that were conducted by administrative nurses/designee with alert and oriented residents to determine if there were any residents who did not feel safe in the facility. The reviewed safe surveys did not reveal any additional resident that caused fear or abuse. On 10/18/2024 reviewed nursing staff in-services dated 10/13/23 that provided education for non-alert and non-oriented residents to monitor for changes in behavior and skin during weekly skin assessments for non-verbal signs and symptoms of abuse. On 10/18/24 reviewed in-services that provided education for all staff on the facility's Abuse and Neglect policy dated 10/13/24 including types of abuse, reporting, who the facility abuse and neglect coordinator was, and signs of abuse. On 10/18/24 reviewed in-serves confirming DON trained and informed staff that 1 to 1 for resident is 24-7 and the staff were trained to make sure resident was in eyesight for safety. Staff members assigned to 1:1 will be in-serviced by Director of Nursing and/or designee on responsibilities to include keeping resident within eyesight at all times and maintaining resident safety. Staff interviewed confirmed this in-service occurred prior to the start of each 1:1 shift and will continue while resident remains 1:1. In an interview with the DON on 10/18/24 11:40 AM the DON stated all training was completed with staff on 10/13/24 on abuse neglect. Any PRN staff will be trained prior to working shift they are scheduled for. She trained and informed staff that 1 to 1 for resident is 24-7 and the staff were trained to make sure resident was in eyesight for safety. In an interview on 10/18/24 2:15 PM with RVP he stated he in-serviced the Administrator and the DON on 10/12/24 on facility abuse neglect policy. In an interview with the DON on 10/18/24 at 11:40 PM she revealed she was in-serviced by the RVP on different types of abuse/neglect including types of abuse (mental, physical, and verbal) and to report to the Administrator immediately if she ever witnessed any abuse. In an interview on 10/18/24 2:15 PM with RVP he stated he in-serviced the Administrator and DON regarding 1:1 supervision to include keeping resident within eyesight at all times and maintaining resident safety. In an interview on 10-18-2024 at 12:15 PM with CNA E she stated she had been 1 to 1 with Resident #2 since 8:00 AM that morning and will continue to be 1 to 1 until the end of her shift at 10:00 PM. CNA E stated that Resident #2 was to have 1 to 1 24-7. CNA E stated she had signed off on training by the DON on 10-16-2024 on abuse and neglect training and understood that during the 1 to 1 for Resident #2 she needed to make sure he was always in view(eyesight) for the resident safety. She was trained on abuse neglect and knew the different types (mental, physical, and verbal), the signs of abuse (bruises and emotional changes or indicators) and knew to report immediately to the abuse coordinator (ADM) if ever witnessed. During interviews on 10/18/24 from 11:40 AM - 3:50 PM, one RN, three LVNs, and five CNAs (from different shifts) all stated they were in-serviced and abuse and neglect. All were able to state that the Administrator was the Abuse and Neglect Coordinator and give examples of different types of abuse such as physical, verbal, emotional, and psychosocial. All stated if they saw a resident being abused by a staff member, another resident, or a family member they would intervene to ensure the resident was in a safe space and would notify the Administrator immediately. They all stated if the Administrator or DON was not immediately available, they would call the HHSC hotline (and were able to report where the number was posted). They all stated it was important to notify the Administrator because a thorough investigation was necessary to ensure residents safety, and report to the appropriate agencies. Reviewed documentation of Ad HAC QA meeting attended by the DON, Administrator, the MD, confirming review all aspects of Immediate Jeopardy and Initial Plan of removal including in-serving in progress and procedural changes made moving forward. While the IJ was removed on 10/18/24 at 5:00 PM, the facility remained out of compliance at a scope of pattern and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Based on observation, interview, and record review the facility failed to ensure adequate supervision and assistive devices to prevent accidents for 1of 6 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident # 1 was free from accidents. Resident # 1's leg was hit on a table by CNA A that resulted in a Tibial fracture to her right leg and was sent to the hospital for treatment services. The staff who caused the injury was moved to another hall. This failure placed residents at risk of being injured by CNA A. Findings included: Resident #1 was a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses of Unspecified dementia (progressive or persistent loss of intellectual functioning, with impairment of memory and thinking), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Record review of Resident's #1 quarterly MDS dated [DATE] reflected Resident #1 has a BIMS score of 3 indicating severe impairment. Section GG functional ability reflected Resident # 1 was dependent for dressing, showering, putting on clothes, and toileting. Section J Health condition reflected Resident #1 had a history of falls and 1 fall since being admitted the facility. Record review of Resident #1 care plan dated 2/5/2024 reflected Resident #1 assessed for falls with interventions: Call light within reach, Fall mat beside bed. Record review of the facility progress note dated 4/8/2024 regarding an incident on 4/5/2024 by LVN D reflected the following: Resident #1 notified therapy that her right knee was hurting. Therapy placed ice on it. NP notified and gave orders for STAT right knee Xray. Xray ordered. Resident told therapy someone pushed me under the table and hit my knee. During an Interview on 4/16/2024 at 1:38pm with CNA A revealed she was pushing Resident # 1 up to the dining table and hit Resident # 1's leg on the table. CNA A stated she did not realize Resident #1 had her leg up, she stated the impact did not seem that hard, so she did not let the nurse know. CNA A stated she straightened out Resident #1's leg and pushed her up to the table. CNA A stated she later found out that Resident #1's leg had swelled up and there was a fracture. CNA A stated she was moved to another hall at the request of the family. During an interview on 4/16/2024 at 2:09pm with LVN A, stated on 4/5/2024 later that day Resident # 1 went to therapy. LVN A stated she was advised by therapy that Resident #1's knee was swollen and unable to bend. She stated they ordered x-rays 'Stat and found received the results the following day on 4/6/202, she stated the results indicated there was a fracture. LVN A stated Resident #1 was sent to the hospital for more treatment services. LVN A stated CNA A should have gotten a nurse at the time when she hit the resident's knee on the table. During an interview on 4/16/2024 at 3:50pm with the DCO, revealed she was made aware of the incident the next day when she was advised Resident #1 was sent out to the hospital. The DCO stated she was advised by LVN A, that Resident # 1 hit her knee and yelled out ouch. The DCO stated CNA A should have gotten the nurse to assess the resident at that time she hit her leg. During an interview on 4/16/2024 at 4:05pm with the EDO revealed there was no investigation completed because they were able to determine what happened. The EDO stated CNA A should have reported hitting Resident #1's leg to the nursing staff. He stated CNA A was moved from Resident #1's hall at the request of the family due a previous fall in which this staff was on duty. The EDO stated the family felt it would be best if she did not work on that hall anymore, so she was moved to another hall. The EDO stated they did not think that it was intentional by CNA A that she hit her leg and stated that was the extent of their investigation. Record Review of Resident # 1's hospital discharge medical records dated 4/6/2024. The medical records reflected Resident #1 was admitted to theER on [DATE]. The medical records reflected Resident #1 sustained a Tibial fracture to the right leg. The medical records reflected Resident # 1's right leg was placed in a splint and medication for pain was prescribed. Resident # 1 was released from the hospital later the same day on 4/6/2024 back to the facility. Record review of the facility Abuse/Neglect policy dated 2/1/2017, the policy reflected the following: Each resident has the right to be free from Abuse/Neglect Resident will not be subjected to abuse/neglect by anyone. Record review of facility Incident an Accident policy dated 3/1/2017 reflected the following: Accidents or incidents involving residents shall be investigated and reported to the EDO.

Based on observation, interview, and record review, the facility failed to ensure the resident was free from abuse for 5 (Residents #2, #3, #4, #5 and #6) of 5 residents reviewed for abuse. The facility failed to ensure Resident #2, #3, #4, #5 and #6 were protected from physical and verbal abuse including verbally and physically aggressive behavior, such as physically punching, cursing, insulting, and intimidation from Resident #1. As a result of the facility's failures Residents #2, #3, #4, #5 and #6 suffered continual negative psychosocial outcomes including crying, fear and anxiety, feelings of hopelessness, and withdrawal from former social patterns. An IJ was identified on 07/15/23. The IJ template was provided to the facility on [DATE] at 8:30 PM. While the IJ was removed on 07/16/23 at 4:36 PM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate to resident health or safety due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure caused actual harm to 5 residents and placed all residents in the facility at risk for physical abuse, verbal abuse, severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of Resident #1's undated face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: epilepsy (seizures), cerebral infarction (stroke), hemiplegia (partial paralysis), insomnia, depression, repeated falls, mood disorder, and anxiety. Record review of Resident #1's quarterly MDS , dated 05/30/2023 revealed: Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section E Behavior Symptom - presence and frequency revealed a 0 for physical behavioral symptoms directed toward others, verbal behavioral symptoms directed towards others, and other behavioral symptoms not directed toward others; this indicated that these behaviors were not present. Record review of Resident #1's care plan dated 06/01/23 revealed Resident #1 is/has potential to be physically aggressive. 04/13/21 physical altercation with roommate, 04/24/23 physical altercationnwith another resident no injuries, 07/09/23 physical altercation with another resident, no injuries, 07/12/22 physical altercationn with another resident, no injuries. Interventions included monitor, document, report as needed any symptoms of Resident #1 posing danger to self and other. It further revealed that Resident #1 had physically assaulted Resident # 2 on 07/9/23 and Resident #3 on 07/09/23. Record review of Resident #1's progress notes, printed 07/15/23 revealed: 07/10/23 1:42 PM Nurse note authored by LPN A: During report off going nurse made me aware of this resident involved in an altercation after finishing lunch. This resident slapped Resident #2. 07/10/23 10:02 PM Nurse note authored by LVN A: Resident is to remain one on one until 1:00 PM on 07/10.23. Resident is in his room this time with a nurse. No behavioral problems noted at this time. 07/12/23 12:14 PM Nurse note authored by LVN A: was told by another resident that this resident hit Resident #3 on the left side of his head when he was coming in from smoking without provocation. I went and asked Resident #3 what happened and he stated that I didn't do anything to him. He just hit me. I asked Resident why he hit Resident #3 and he stated he called me a bastard. Call placed to DR A and new order received and noted to place resident one on one and get a physic evaluation. Resident brother stated that his brother needed help because he had angry issue. Resident was placed one on one as per orders and call placed to the psychiatrist. 07/12/23 8:00 PM Nurse note authored by LVN A: Resident remains one on one throughout shift. No behaviors noted. Record review of the facility's incident list, printed on 07/15/23 revealed abuse reports for the progress notes reviewed above. Record review of faciliy abuse report dated 07/09/23 revealed Resident #1 was sitting at table table eating lunch when Resident #2 was moving past him. Resident #2 stopped and began saying something to Resident #1'. After a moment Resident #1 turned around and slapped Resident #2. Record review of facility abuse report dated 07/12/23 revealed Resident #3 was out in the smoking area when Resident #1 brought his arm up and slapped Resident #3. Record review of Resident #2's undated face sheet revealed that he was a [AGE] year-old male admitted [DATE] with diagnoses including traumatic brain injury, intermittent explosive disorder (unpredictable outbursts of anger), falls, dementia, anxiety, and depression. Record review of Resident #2's quarterly MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed a score of 09, which indicated the resident's cognition was moderately impaired. Record review of Resident #3's undated face sheet revealed that he was an [AGE] year-old male admitted [DATE] with diagnoses including major depressive disorder and anxiety disorder. Record review of Resident #3's quarterly MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Record review of Resident #4's undated face sheet revealed that he was a [AGE] year-old female admitted [DATE] with diagnoses of schizophrenia and homelessness. Record review of Resident 4's quarterly MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed no score which indicated unable to determine resident # 4's cognition. Record review of Resident #5's undated face sheet revealed a [AGE] year-old female originally admitted [DATE] with diagnoses including: type 2 diabetes, obesity, hepatitis C, dementia, bipolar disorder, and absence of left leg below the knee. Record review of Resident #5's most recent MDS dates 05/31/23 revealed: Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Record review of Resident #6's undated face sheet revealed that he was a [AGE] year-old male admitted [DATE] with diagnoses including: type 2 diabetes, anxiety, bipolar disorder, stroke causing partial paralysis, repeated falls, and Parkinson's. Record review of Resident #6's quarterly MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was intact. An interview on 07/15/23 at 11:26 AM revealed the interim DON stated Resident #1 slapped Resident # 2 on 07-09-23 and Resident # 3 on 07-12-23. Resident #1 was placed back on 1 on 1 but could not recall the date placed on 1 on 1 or the reason Resident #1 was removed from 1 on 1 after the first incident but could not give an exact date Interim DON stated she was not at the facility when the two incidents occurred but stated Resident #1 had a history of being physically and verbally abusive with other residents. An interview on 07/15/23 at 12:45 PM revealed the Administrator stated Resident #1 punched Resident #2 on 7-9-23 and Resident # 3 on 7-12-23 in the face. Resident #1 was placed on 1 on 1 after the first incident on 7-9-23 The Administrator was unable to provide an exact date Resident #1 was taken off 1 on 1 after the first incident. Resident # 1 was not experiencing any behaviors after being placed on 1 on 1. An interview on 07/15/23 at 1:30 PM revealed Resident #5 stated she did not feel safe at the facility. Resident #5 stated she is fearful of being hit by Resident #1. Resident #5 stated that Resident # 1 had hit Resident #3 and Resident #4 and she did not like living at the facility in fear. Resident #5 stated she is not happy with Resident #1 getting away with the things he is doing. Resident #5 stated a couple of weeks ago (could not recall exact date and time) Resident #1 raised his cell phone over his head as he was going to hit her. Resident # 1 was using profanity towards her and making fun of her having one leg. Resident #5 stated she was in fear of Resident #1 that he will eventually hit and harm her. Resident # 5 stated she just wanted to enjoy being at the facility again without fear. An interview on 07/15/23 at 1:45 PM revealed Resident #6 stated he was not happy at the facility and in fear of Resident # 1. Resident #6 stated Resident # 1 had hit Resident #2 and Resident #3 and nothing had been done about it. Resident #6 stated he was in fear of safety and not comfortable being around Resident #1. Resident #1 hit his friend Resident #3 on the side of his face with his fist. Resident #3 was trying to come back inside from being outside and Resident #1 was blocking the door to come inside. Resident #3 was trying to go around Resident #1 when Resident #1 physically hit Resident #3 in the face. Resident #6 stated he did not believe the facility was not doing anything about Resident #1's behavior towards residents. An interview on 07/15/23 at 1:55 PM revealed Resident #4 stated she witnessed Resident #1 hit Resident #3. Resident #4 stated on 7-12-23 she was standing out taking a smoke break and Resident #3 was trying to come back inside and Resident #1 was in front of the door and punched Resident #3 for nothing. Resident #4 stated she was scared for her safety as Resident #1 may one day hit her for nothing. Resident #4 stated the facility need to do something about Resident #1 hitting people and that was not the only time he had hit someone. Resident #1 hit Resident #2 was what she was told by other residents at the facility. Resident #4 stated after witnessing Resident # 1 verbally and physically abuse Resident #3 she was in fear of being safe. An interview on 07/15/23 at 2:15 PM revealed Resident #3 stated he was hit by Resident # 1 when he came back into the building. Resident #3 stated Resident #1 punched him on the left side of his face with his fist. Resident #3 stated he asked Resident #1 could he move so he could go in and when he tried to go around him that's when Resident #1 hit him. Resident # 3 stated he had a headache for a couple of days and had not felt safe since the incident. Resident #3 stated he did not feel comfortable with Resident #1 and was in fear of Resident # 1 hitting him again. Resident # 3 stated the incident had mentally affected him as he was embarrassed for being hit in the face for no reason. Resident #3 stated he did not feel protected with Resident #1 at the facility and that he did not want to come out of his room hardly. An interview on 07/15/23 at 3:00 PM revealed Resident #2 stated he was hit by the big black man on the side of his face. Resident #2 stated he was in the dining room and did not know why he hit him. Resident #2 stated he did not feel safe because he is in a wheelchair and not able to take up for himself. Resident #2 did not further elaborate on the incident. An interview on 07/15/23 at 3:15 PM revealed Resident #1 would not talk or communicate what happened with the incidents. Several attempts were made to obtain an interview with Resident #1 was unsuccessful. Resident # 2 wheeled by Resident #1's room in wheelchair and Resident #1 seen Resident # 2 in the hallway from the room and Resident # 1 looked at surveylor and stated he hit him real hard several times. Attempted again to interview Resident #1 and Resident #1 no longer responded. An interview on 07/15/23 at 3:42 PM revealed LVN B stated that she heard about the incidents with Resident #1 but she was not in the facility when they occurred. LVN B stated Resident # 1 had a history of being physically and verbally abusive with residents. LVN B could not give a date when Resident #1 was removed from 1 on 1 previous. An interview on 07/15/23 at 4:10 PM revealed RN Supervisor stated he was not in the facility with the incident with Resident #3 but was in the facility with the incident with Resident #2. The incident with Resident # 2 happened on 07/09/23 in the dining room. RN Supervisor stated he did not witness the incident but assessed Resident #2. Resident #2 stated the big black guy had hit him and he did not know the reason why. RN Supervisor spoke with Resident #1 and he told him that he hit Resident #2. Resident # 1 stated that Resident #2 was pouring sugar on the ground and going back and forth to Resident #1's table messing with him and Resident # 1 hit Resident # 2. RN Supervisor stated all the behaviors have been seen last two weeks. An interview on 07/15/23 at 4:45 PM was attempted with LVN A left a voice mail to return the call. An interview on 07/15/23 at 4:55 PM revealed CNA A stated she was monitoring the cigarette smoke break and not monitoring a 1 on 1 with Resident # 1. CNA A stated she did not know Resident #1 was assigned to 1 on 1. CNA A stated she was lighting a resident's cigarette and was told by Resident # 4 that Resident # 1 hit Resident #3. CNA A stated that Resident #4 stated Resident #1 hit that man for nothing. An Interview on 07/15/23 at 5:17 PM revealed LVN C stated he was on dining room duty monitoring the residents eat when he heard a loud sound. LVN C stated he did not see the hit and Resident #2 told him that he had gone to Resident #1 table by accident and that's when Resident # 1 hit him. Record review of inservice on abuse dated 07/12/23 all staff completed the training Record review of of safe surveys dated 07/12/23 completed by all residents. Record review of the facility abuse policy, dated 02/1/17, revised 01/27/23; The purpose of this policy is to ensure each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement, and or Misappropriation of property. The facility staff will adhere to the policies and procedures and will follow the guidelines in written policy and procedure. The facility administrator is the appointed Abuse Coordinator, and in his/her absence a designee will be appointed. 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. On 07/15/23 at 8:30 PM the Administrator and Interim DON were informed that an Immediate Jeopardy (IJ) for abuse was identified and were provided the Immediate Jeopardy template. On 07/16/23 at 4:36 PM the following plan of removal was accepted: Impact Statement Abuse The resident has the right to be free from abuse, neglect, misappropriation of resident property as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Identify residents who could be affected All residents who encounter Resident #1 have the potential to be affected by this alleged deficient practice. Problem The facility failed to prevent ongoing aggressive behaviors from Resident #1. Action Taken Resident #1 was 1:1 on 7-15-2023 and will remain 1:1 until Resident #1 transfers to alternate facility. Facility has alternate placement for Resident #1 with transfer date of 7/17/2023. Alternate placement has been secured for Resident #1. Staff members will be assigned and notified of assignment to include always keeping resident within eyesight. Education was provided by Interim Director of Clinical Services and/or designees on 7-15-2023. Staff were educated in person and via telephone for staff that was not present. The administrator will oversee actions taken. Psych services was consulted on 7-15-2023 to evaluate Resident #1 to determine a course of treatment to assist with inappropriate behaviors by Assistant Director of Clinical Services. Safe Surveys were conducted by administrative nurses/designee with alert and oriented residents to determine if there were any residents who did not feel safe in the facility on 7-16-2023. Alert and oriented is defined by the resident's being alert and oriented to person, place, time and event. Verification of completion was done by the Administrator on 7-16-2023. Safe surveys included Are you fearful of other residents? Have you witnessed aggressive behavior by other residents? Safe survey did not reveal any additional resident that cause fear or abuse. Regional Director of Clinical Operations educated administrator and Interim Director of Nursing on reporting of abuse and neglect allegations on 7-15-2023. The Interim Director of Nursing and/or designee began educating all staff on the facility's Abuse and Neglect policy on 7-15-2023. All staff will be educated prior to their next assigned shift. Training will continue until all staff have been educated either in person by Interim DCO or ADCO on 7-16-2023. Interim DCO and Administrator will verify education has been completed prior to their next assigned shift. The Interim Director of Nursing and/or designee educated staff on completion of incident reports on 7-16-2023. All nurses will be educated prior to their next assigned shift. Training will continue until all nurses have been educated. This training will be part of any new hire orientation for nurses. Involvement of Medical Director and Quality Assurance Ad HOC QA meeting held with the medical director on 7-15-2023 at 9:19 pm to review all aspects of Immediate Jeopardy and Initial Plan of removal. QAPI meetings are held on a monthly basis and all allegations of physical aggression by Resident #1, incidents, and accidents will be reviewed during the QAPI meeting. This will be an ongoing process. POR monitoring . An observation on 07/16/23 at 11:00 AM revealed Resident #1 in a 1-to-1 with a CNA B in his room. An observation on 07/16/23 at 11:45 AM revealed Resident #1 in a 1-to-1 with a CNA B in his room. An observation on 07/16/23 at 12:30 PM revealed Resident #1 in a 1-to-1 with a CNA B in his room. An interview on 07/17/23 at 11:00 AM revealed LVN B stated she trained on Abuse & Neglect on 07/16/23. LVN B know the signs of abuse who to report to, and make sure Residents are safe. LVN B gave five types of abuse identified and one example of neglect. An interview on 07/17/23 at 11:13 AM revealed the Housekeeping Supervisor stated he know the signs abuse to the Administrator if suspected. The Housekeeping Supervisor stated abuse and neglect training are held weekly and he gave an example of neglect. An interview on -7/17/23 at 11:22 AM revealed CNA C received the training to report to Administrator if abuse is suspected. CNA C gave examples of abuse. An observation on 07/17/23 at 1:56 PM revealed Resident #1 in a 1-to-1 with a CNA B in his room An interview on 07/17/23 at 1:58 PM revealed LVN A was called by phone on 07/16/23 to complete training on incident documentation on abuse. LVN A know to report to the Administrator and gave examples of abuse. An interview on 07/17/23 at 2:07 PM revealed The Receptionist was trained on abuse and neglect. The Receptionist know to report any suspected abuse to the Administrator and DON. Record review of the medical records safe surveys were conducted on 07/17/23. In addition, psych services were consulted according to the medical records. On 07/16/23 The Administrator and interim DON was informed the IJ was removed 07/16/23 at 4:36 PM. However, the facility remained out of compliance at actual harm that is not immediate and a scope of a pattern due to the facility's need to monitor the evaluate the effectiveness of their plan of removal.

Based on observation, interview, and record review, the facility failed to ensure the resident was free from abuse for 4 (Residents #2, #3, #4, and #5) of 5 residents reviewed for abuse. The facility failed to ensure Resident #2, #3, #4, and #5 were protected from verbal abuse including verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group and intimidating from Resident #1; and sexually lewd behavior and questions; including urination in cups at breakfast from Resident #6. As a result of the facility's failures Residents #2, #3, #4, and #5 suffered continual negative psychosocial outcomes including crying, fear and anxiety, feelings of hopelessness, and withdrawal from former social patterns. An IJ was identified on 03/11/23. The IJ template was provided to the facility on [DATE] at 6:45 pm. While the IJ was removed on 03/13/23 at 4:45 pm, the facility remained out of compliance at a scope of pattern and a severity level of actual harm to resident health or safety due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure caused actual harm to 4 residents and placed all residents in the facility at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings included: Abuse neglect and exploitation policy Record review of the facility abuse policy, dated 2/1/17, revised 1/1/23; right to be free from any type of abuse . Residents will not be subjected to abuse by anyone including other residents This includes physical, verbal, sexual (including indecent exposure), physical/chemical restraint Record review of Resident #1's undated face sheet revealed a [AGE] year-old male admitted to the facility 10/23/21 with diagnoses including: epilepsy (seizures), cerebral infarction (stroke), hemiplegia (partial paralysis), insomnia, depression, repeated falls, mood disorder, and anxiety. Record review of Resident #1's quarterly MDS , dated 12/09/22 revealed: Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section E Behavior Symptom - presence and frequency revealed a 0 for physical behavioral symptoms directed toward others, verbal behavioral symptoms directed towards others, and other behavioral symptoms not directed toward others; this indicated that these behaviors were not present. Record review of Resident #1's undated care plan revealed: he has a history of high-risk heterosexual behaviors, makes sexual advances towards female staff members and grabs their private parts and touches them inappropriately. Intervention included monitoring every shift and redirecting. It further revealed that Resident #1 has a potential to be physically aggressive, he assaulted his roommate 04/13/21. Record review of Resident #1's progress notes, printed 03/13/23 revealed: 03/09/23 9:23 pm behavior note: Resident had several issues today where he hit this nurse and other staff . hit this nurse four times 10/28/22 8:18 am nurse note: Resident in hall way and called another female resident a bitch 08/01/22 12:47 pm nurse note: resident and another got in altercation and were hitting each other outside in smoking area, 07/13/22 6:30 am nurse note: resident angry called nurse a bitch and demanded she come to his room now, 07/12/22 1:09 pm nurse note: housekeeper saw Resident #1 in another resident room and asked him to leave and he started hitting her with a wash cloth and refused to stop when asked 07/10/22 10:15 am nurse note: Resident #1 pointing at vagina of staff stating I want that pussy and I'm watching your ass , 07/03/22 1:40 am behavior note: Resident #1 tried to reach down CNA top, tried to kiss her while she changed his brief, This is a frequent behavior from resident 05/26/22 11:45 am nurse note: resident in dining room blaring music, said fuck you when nurse asked him to lower volume, only lowered it after several requests, record review of facility incident list printed 03/13/23 showed no incident report on this date 05/26/22 8:20 am behavior note: wanted to smoke, tried to hit staff with wheelchair, told female resident to shut her mouth and called her a fat bitch, note states this is not the first time he behaved like this 4/13/21 Note Text: CNA reported to this nurse that this resident bumped into his roommate's wheelchair and hit resident with his fist. Both residents became physically aggressive towards each other. Resident denies physical altercation, but roommate states resident punched him after moving his wheelchair off of his leg, roommate states he hit resident back after he was hit, residents separated at this time resident moved to another room, Dr. notified, and family member notified, Will continue to monitor. Record review of the facility's incident list, printed on 03/13/23 revealed no incident reports no incident report for any of the progress notes reviewed above. Record review of the grievance log shows Resident #1 was in an altercation with another resident on 03/08/22. Record review of Resident #2's undated face sheet revealed a [AGE] year-old female originally admitted [DATE] with diagnoses including: type 2 diabetes, obesity, hepatitis C, dementia, bipolar disorder, and absence of left leg below the knee. Record review of Resident #2's most recent MDS date 01/30/23 revealed: Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Record review of Resident #3's undated face sheet revealed that he was a [AGE] year-old male admitted [DATE] with diagnoses including: type 2 diabetes, depression, dementia, and anxiety. Record review of Resident #3's quarterly MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed a score of 14, which indicated the resident's cognition was intact. Record review of Resident #4's undated face sheet revealed that she was a [AGE] year-old female first admitted to the facility on [DATE], and most recently admitted on [DATE] with diagnoses including: Chronic post-traumatic stress disorder, major depressive disorder, obesity, hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke), and obesity. Record review of Resident #4's significant change MDS, dated [DATE], revealed: Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Record review of Resident #5's undated face sheet revealed that he was a [AGE] year-old male admitted [DATE] with diagnoses including: type 2 diabetes, anxiety, bipolar disorder, stroke causing partial paralysis, repeated falls, and Parkinson's. Record review of Resident #5's quarterly MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was intact. Record review of Resident #6's undated face sheet revealed that he was a [AGE] year-old male admitted [DATE] with diagnoses including traumatic brain injury, intermittent explosive disorder (unpredictable outbursts of anger), falls, dementia, anxiety, and depression. Record review of Resident #6's admission MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed a score of 11, which indicated the resident's cognition was moderately impaired. Section E Behavior Symptom - presence and frequency revealed a 0 for physical behavioral symptoms directed toward others, verbal behavioral symptoms directed towards others, which indicated that the behavior did not occur and 1 for other behavioral symptoms not directed toward others; this indicated that these behaviors occurred 1 to 3 days. It further indicated on E0500 Impact on the resident was marked as 0 indicating behaviors did not impact the resident. On section E0600 Impact on Others was marked 0 indicating the behaviors did not impact other residents. Record review of Resident #6's undated care plan revealed The resident has a behavior problem related to inappropriate behaviors, cusses, talks inappropriate to staff, throws urine on floor, turns over bedside table when laying in bed; Resident will place himself on the floor to urinate and defecate on floor. Resident will inappropriately touch staff at times. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Minimize potential for the resident's disruptive behaviors inappropriate touching and urinating in cups by offering tasks which divert attention such as puzzles. Record review of Resident #6's progress notes, printed 3/11/23 revealed: Nurses note dated 3/6/23 9:46 pm resident removed his brief and threw it on the floor, also urinated in cup and threw it on the floor Nurses note dated 3/6/23 12:19 pm resident was banging on walls all morning long, continues cussing at staff Nurses note dated 3/4/23 12:39 pm resident yelling and cursing at staff Nurses note dated 3/3/23 1:19 pm resident yelling, banging on walls, cursing at staff Nurses note dated 3/3/23 3:37 am resident banging on walls Nurses note dated 3/2/23 10:49 am resident banging on walls, yelling, cursing staff, calling them bitch Nurses note dated 2/27/23 12:16 pm resident banging on walls and yelling Nurses note dated 2/26/23 11:05 am resident in sunroom with female resident and proceeded to pee in cup, educated, stated he did not care Nurses note dated 2/24/23 12:52 pm resident in dining room attempting to urinate in flower vase Nurses note dated 2/24/23 9:07 am resident banging on walls, bed pulled from wall, pouring urine on floor, roommate stated all night long pouring urine on floor, nurse went to tell him to stop banging on the walls he stated you bitch, you bitch I will punch you in your fucking face Nurses note dated 2/22/23 1:59 pm resident peeing in hallway Nurses note dated 2/10/23 12:11 pm yelling at housekeeper to suck his penis and calling her a bitch. Nurses note dated 2/8/23 Note Text: Resident was in the dining room for breakfast and he was trying to pee in a plastic cup like he did yesterday. He was taken out and taken to his room. Nurses note dated 2/7/23 Note Text: Resident was cursing the CNA this morning calling her a Bitch. Following her down the hallway. He then started yelling at another CNA and I informed him to stop. Resident went into the dining room and peed in a glass and poured it in the floor Resident #6 was not interviewable. In an interview and observation on 03/10/23 at 3:37 pm with Resident #4, she stated, Resident #1 is angry she was elected to the Resident Council and not him. She stated she felt harassed by him since she arrived in December. She stated he was also hostile towards her and she constantly feared encountering Resident #1. He also called her a fat cow, she told administrator two or three weeks ago, who told him not to do it anymore, but she said he harasses her and she tries to avoid him at all times. He plays his music so loud that it disrupts her sleep and rest and the music is vulgar. He cranks it in the dining room and common areas too. He was in a resident room and raised his hand to hit a little lady in a wheelchair who has severe dementia until Resident #4 intervened verbally. While surveyor was speaking with Resident #4, Resident #1 approached to try to listen in to the conversation and ended up kicking the back of Resident #4's wheelchair. Staff that were outside in the smoking area did not intervene when Resident #1 approached Surveyor and Resident #4 during interview. She stated Resident #1 continues to harass her, call her names and cause her distress. She stated it began when he made sexual advances towards her that she declined. Resident #4 said he has brought her to tears at times and that she has to walk on eggshells and try to avoid contact with Resident #1. When Resident #4 was describing the interactions with Resident #1 she appeared distressed and her eyes watered. At times her voice trembled as she recounted specific details. She stated that her room was directly across the hall from his room, and he blares vulgar music in common areas and in his room (which disrupts her). Resident #4 stated she told the ADM about the inappropriate advances and him calling her names and nothing changed. She also stated she was tired of Resident #6 being disruptive, which included him urinating on her chair in the dining room, urinating in cups in the dining room, and constant banging on walls and screaming and cursing. In an interview and observation on 03/13/23 at 6:43 pm with Resident #4, she stated that she liked her roommate and that she was upset because Resident #1 was across the hall, but it was very hard that her tormentor is across the hall because it was a reminder of my abuse and the only time I feel 100% safe is when he is in his bed. She stated she felt safe when he was in bed because he was partially paralyzed and not able to get out of bed without staff assistance While being interviewed outside in the smoking area, Resident #1 was outside with one aide watching the 7 residents outside; as Resident #4 was speaking with surveyor, Resident #1 wheeled over to within 2 feet of Resident #4 and no staff intervened. Resident #4 stated that if she made an allegation of abuse that she would be moved from her room, which greatly upset Resident #4 because she stated she helps her roommate and cares for her. In an interview and observation on 03/10/23 at 3:37 pm with Resident #5 stated Resident #1 blares loud music and he feels bullied by Resident #1 and 2 other residents also bullied him, all of whom hang out. One of the reasons he resigned from the office on the Resident Council to which he was elected after less than 1 week is intimidation by Resident #1. He stated that he does not attend social events anymore due to fear of running across Resident #1. He stated he would enjoy these activities if Resident #1 were not present. Resident #5 stated that he is disgusted by the behavior of Resident #6 and that he doesn't belong at the facility with all of his sexually lewd talk and inappropriate behaviors such as urinating in the dining room. During the interview with Resident #5 his voice trembled and his hands started to shake when he described encounters with Resident #1 and his ongoing fear of being bullied by Resident #1 and the other 2 residents that bullied him. In an interview and observation on 03/10/23 at 3:37 pm with Resident # 3 he stated that Resident #1 threw a bottle of hot sauce on his face in the dining room in front of everyone; he stated a staff member even took pictures, but the staff member was no longer here. He stated this occurred a few months ago, possibly December or January. He stated that Resident #6 was asking sexually inappropriate questions about Resident #3's grandchildren. He stated Resident #6 makes sexually inappropriate comments on a daily basis. He further stated that Resident #6's inappropriate behavior was ignored by staff. When he was describing the sexually inappropriate speech and behavior of Resident #6, he lowered his voice to almost a whisper. When he discussed Resident #1 throwing the bottle of hot sauce on him and constant blaring of inappropriate music his voice became elevated and his face turned red. He reiterated that Resident #1 disrupted the calm environment. On 03/11/23 at 12:00 pm during an interview with Interim DON the results of the safe surveys were reviewed and an additional victim of verbal abuse, Resident #2 was identified as being fearful of Resident #1. In an interview and observation on 03/11/23 at 3:00 pm with Resident #2 she stated that Resident #1 has on 5 or 6 occasions called Resident #2 names such as 1 legged bitch and fat slob. This verbal abuse started about a year ago, and she stated she has told the prior administrator, the current interim administrator, and the interim director of nurses and all said they would talk to him. She won't cry in front of him but goes to her room and sobs uncontrollably. This has caused her to change directions any time she sees him, avoid activities when he is present and causes her ongoing anxiety. She cried after each event. She also witnessed him and another resident almost come to blows (engage in physical aggression). When she was being interviewed, Resident #2 appeared tearful and agitated. She was emotional as she spoke. In an interview with Resident #1 on 03/11/23 at 9:25 am he stated that Resident #4 doesn't do her job as an elected official on the Resident Council like he did when he [NAME] the position; she hasn't been here 6 months and he has been here over 2 years. He complained the whole cabinet was appointed by her and all of them are White (all positions are elected per DON). He stated she doesn't care about Black residents. When he was on the council he got up and did rounds on all of the residents in the facility. He stated, I admit, I called her a pig, one time. He stated she doesn't like Black people, but he doesn't know if it just him. He also admitted throwing a bottle of hot sauce at another resident. In an interview on 03/09/23 at 2:00 pm with the DON and ADM, the Adm stated that Resident #1 called Resident #4 a fat pig. He stated he spoke to Resident #1 and told him he could not talk to people like that and the resident apologized and stated he would not do it again. In an interview on 03/10/23 at 8:30 am with the DON and ADM, the DON stated that the three residents who were the victims of abuse all had psychological diagnoses and asked where does Resident #1's rights stop; DON stated that is how he was raised . The ADM stated that Resident #5 was a music teacher and is just sensitive. He further stated he did not get involved with petty disputes between residents. They both denied knowledge of Resident #1 throwing a bottle of hot sauce at Resident #3, which caused it to shatter on his beard. They stated Resident #6 had these behaviors, such as sexually inappropriate comments and banging on the walls all nights, and urinating in public places. DON stated he apologized when she spoke to him, but then resumed the behaviors; she did stated that Resident #6 knew what he was doing and continued the behaviors. On 03/11/23 at 6:45 pm the Interim DON and Interim Administrator were informed that an Immediate Jeopardy (IJ) for abuse was identified and were provided the Immediate Jeopardy template. On 03/13/23 at 4:45 pm the following plan of removal was accepted: Impact Statement F600 Abuse The resident has the right to be free from abuse, neglect misappropriation of resident property as defined in this subpart. This includes but is not limited to freedom from corporal punishment involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Identify residents who could be affected All residents who came into contact with Residents #1 and #6 have the potential to be affected by this alleged deficient practice Problem F600- The facility failed to prevent ongoing verbally aggressive behaviors, such as screaming, cursing, bossing around/demanding, insulting race or ethnic group, intimidating, sexually lewd behavior and questions; including urinating in cups at breakfast by 2 residents resulting in 4 residents reporting secluding in rooms and/or avoiding activities previously enjoyed. Action Taken Resident #1 was placed on 1:1 on 3/10/23 and it will be ongoing until residents exhibit improved behaviors or alternate placement is arranged; the Interim Direct of Nurse will ensure the resident remains on 1:1. Beginning 3/10/23 at 5pm Staff members will be assigned and notified of assignment to include always keeping resident within eyesight. The interim administrator will oversee actions taken. Resident #6 was placed on 1:1 on 3/10/23 Resident will remain 1:1 until behaviors are improved or alternate placement is arranged; the Interim Direct of Nurse will ensure the resident remains on 1:1. Beginning 3/10/23 at 5pm Staff members will be assigned and notified of assignment to include always keeping resident within eyesight. The interim administrator will oversee actions taken. Psych services were consulted on 3/11/23 to evaluate both Resident #1 and Resident #6 to determine a course of treatment to assist with alleged inappropriate behaviors. Psych services will provide counseling on 3/12/23. Psych services will be care planned on 3/12/23 by the Regional Clinical Reimbursement Coordinator. Verified by Corporate Clinical Reimbursement Specialist. Psych services were consulted on 3/11/23 to evaluate Residents #2, #3, #4, and #5 to assist with any alleged psychosocial distress from behaviors by Residents #1 and #6. Psych services will provide counseling on 3/12/23. Psych services will be care planned on 3/12/23 by the Regional Clinical Reimbursement Coordinator. Verified by Corporate Clinical Reimbursement Specialist. Safe Surveys were conducted by administrative nurses on 3/11/23 with all alert and oriented residents to determine if there were any residents who did not feel safe in the facility. Verification of completion was done by the Interim Administrator. Two residents reported that they did not feel safe, the individuals that they are reportedly fearful of are on 1:1 observation and have been evaluated by psych services and will be seen at least weekly for 4 weeks. Regional Director of Clinical Operations educated Interim administrator and Interim Director of Nursing on reporting of abuse and neglect allegations on 3/11/23. The Interim Director of Nursing and/or designee began educating all staff on the facility's Abuse and Neglect policy on 3/11/23. All staff will be educated prior to their next assigned shift. Training will continue until all staff has been educated. This training will be part of any new hire orientation on the next schedule orientation 3/14/23. The Interim Director of Nursing and/or designee began educating nurses on when to complete an Incident Report on 3/11/23. All nurses will be educated prior to their next assigned shift. Training will continue until all nurses have been educated. This training will be part of any new hire orientation for nurses. This training will be part of any new hire orientation on the next schedule orientation 3/14/23. Involvement of Medical Director and Quality Assurance Ad HOC QA meeting held with the medical director on 03/11/23 at 7:38 pm to review all aspects of Immediate Jeopardy and Initial Plan of removal. QAPI meetings are held on a monthly basis and all allegations, incidents, and accidents will be reviewed during the QAPI meeting. This will be an ongoing process. POR monitoring . An observation on 03/12/23 at 11:15 am revealed Resident #1 at the facility entrance sitting in a wheelchair being assisted by a cna in a 1 to 1 with the resident. An observation on 03/12/23 at 11:20 am revealed Resident #6 in the sunroom sitting in a wheelchair playing a board game assisted by a cna in a 1 to 1 with the resident. An observation on 03/12/23 at 11:45 am revealed Resident #1 in a 1 to 1 with a CNA in his room. An observation on 03/12/23 at 1:00 pm revealed Resident #6 in the sunroom sitting in a wheelchair playing a board game assisted by a cna in a 1 to 1 with the resident. An observation on 03/12/23 at 1:10 pm revealed Resident #1 in a 1 to 1 with a CNA in his room. An observation on 03/13/23 at 6:00 pm revealed Resident #6 was outdoors with a CNA taking a walk one on one. An observation on 03/13/23 at 6:15 pm revealed Resident #1 was observed with CNA one-on-one walking down the hall An interview on 03/13/23 at 6:32 pm revealed that CMA A was able to answer questions regarding abuse, reporting and resident on resident abuse; stated in-service today on abuse. An interview on 03/13/23 at 6:36 pm revealed LVN B was able to answer questions related to abuse, reporting, verbal abuse, and resident abusing other residents and stated she was in-serviced this weekend. Record review of the medical records safe surveys were conducted on 03/11/23. In addition, psyc services were consulted according to the medical records. Based on observation, interview and record review the plan of removal was implemented and the IJ was removed on 03/13/23 at 4:45 pm, the facility remained out of compliance at a scope of pattern and a severity level of actual harm to resident health or safety due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observation, interview, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 (Resident #4) of 1 residents reviewed for trauma-informed care. The facility failed to protect Resident #4 from being re-traumatized by allowing her to be subjected to verbal abuse and verbal sexual abuse which led to her not feeling safe in her environment, feeling fear of being around another resident, and increased anxiety in her environment. This failure placed Resident #4 at risk for severe negative psychosocial outcomes which could prevent her from achieving her highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of Resident #4's undated face sheet revealed that she was a [AGE] year-old female first admitted to the facility on [DATE], and most recently admitted on [DATE] with diagnoses including: Chronic post-traumatic stress disorder, major depressive disorder, obesity, hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke), and obesity. Record review of Resident #4's undated active care plan, accessed 03/13/23 revealed no mention of trauma, post-traumatic stress disorder, nor potential triggers from her history of trauma. Record review of Resident #4's significant change MDS, dated [DATE], revealed: Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section I Active Diagnoses was marked Anxiety, Depression, and Post Traumatic Stress Disorder Section N Medications received A. Antipsychotic - given 7 of the last 7 days, C. Antidepressant - given 7 of the last 7 days, however question Antipsychotic Medication Review, question A was marked with a 0 indicating no antipsychotics were received Section O Special treatments, procedures, and programs, section E Psychological therapy had 0 minutes marked Record review of Resident #4's progress notes revealed a noted on 12/12/22 written by Social Services that stated resident survived physical and sexual abuse as a child. Record review of Resident #4's Medication Administration Report for the month of March 2023 printed 03/13/23 revealed Paroxetine HCl Tablet 40 MG Give 1 tablet by mouth one time a day for depression and Olanzapine Tablet 5 MG Give 1 tablet by mouth one time a day for depression. Record review of Resident #1's undated face sheet revealed a [AGE] year-old male admitted to the facility 10/23/21 with diagnoses including: epilepsy (seizures), cerebral infarction (stroke), hemiplegia (partial paralysis), insomnia, depression, repeated falls, mood disorder, and anxiety. Record review of Resident #1's quarterly MDS, dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section E Behavior Symptom - presence and frequency revealed a 0 for physical behavioral symptoms directed toward others, verbal behavioral symptoms directed towards others, and other behavioral symptoms not directed toward others. In an interview on 03/09/23 at 2:00 pm with the DON and ADM revealed the facility does not currently have an MDS nurse, the facility does not currently have a social worker, and the facility does not currently have an activities director. The ADM stated that Resident #1 called Resident #4 a fat pig. He stated he spoke to Resident #1 and told him he could not talk to people like that and the resident apologized and stated he would not do it again. He stated he filed a grievance report, handed it to the social worker, but she was let go from her position and they are not able to find grievances for February or March 2023. In an interview and observation on 03/10/23 at 3:37 pm with Resident #4, she stated, Resident #1 is angry she was elected to the Resident Council and not him. She stated she felt harassed by him since she arrived in December. She stated he was also hostile towards her and she constantly feared encountering Resident #1. He also called her a fat cow, she told administrator two or three weeks ago, who told him not to do it anymore, but she said he harasses her and she tries to avoid him at all times. He plays his music so loud that it disrupts her sleep and rest and the music is vulgar. He cranks it in the dining room and common areas too. He was in a resident room and raised his hand to hit a little lady in a wheelchair who has severe dementia until Resident #4 intervened verbally. While surveyor was speaking with Resident #4, Resident #1 approached to try to listen in to the conversation and ended up kicking the back of Resident #4's wheelchair. Staff that were outside in the smoking area did not intervene when Resident #1 approached Surveyor and Resident #4 during interview. She stated Resident #1 continues to harass her, call her names and cause her distress. She stated it began when he made sexual advances towards her that she declined. Resident #4 said he has brought her to tears at times and that she has to walk on eggshells and try to avoid contact with Resident #1. She stated she had to attend activities due to her role as elected member of the Resident Council, so it was her duty to attend activities and this would cause her to be around Resident #1. She stated that she dreads being around Resident #1, it caused her cocnern and distress. When Resident #4 was describing the interactions with Resident #1 she appeared distressed and her eyes watered. At times her voice trembled as she recounted specific details. She stated that her room was directly across the hall from his room, and he blares vulgar music in common areas and in his room (which disrupts her). Resident #4 stated she told the ADM about the inappropriate advances and him calling her names and nothing changed. She also stated she was tired of Resident #6 being disruptive, which included him urinating on her chair in the dining room, urinating in cups in the dining room, and constant banging on walls and screaming and cursing. In an interview on 03/10/23 at 6:45 pm with Adm and DON, they both stated they were unaware of Resident #4's diagnosis of chronic Post-traumatic stress disorder. The Adm stated the social worker was terminated in February, which he stated was good because she seemed incompetent. He had no knowledge of Resident #4's trauma, he was aware she had psychological issues. The Adm stated he was not aware of any special planning that was required for survivors of trauma and he did not know if the facility trained staff to protect residents from being re-traumatized as he had not heard of trauma informed care. The DON stated that both she and Adm were interim and had only started recently, so she was not able to speak to the care planning for Resident #4 since she was admitted in December before she started as interim DON. In an interview with Resident #1 on 03/11/23 at 9:25 am he stated that Resident #4 doesn't do her job as an elected member of the Resident Council like he did when he held the position. He stated, I admit, I called her a pig, one time. In an interview and observation with Resident #4 on 03/13/23 at 6:43 pm, she stated that she liked her roommate and that she was upset because Resident #1 was across the hall, but it was very hard that her tormentor is across the hall because it was a reminder of my abuse and the only time I feel 100% safe is when he is in his bed. She stated she felt safe when he was in bed because he was partially paralyzed and not able to get out of bed without staff assistance While being interviewed outside in the smoking area, Resident #1 was outside with one aide watching the 7 residents outside; as Resident #4 was speaking with surveyor, Resident #1 wheeled over to within 2 feet of Resident #4 and no staff intervened. Resident #4 stated that if she made an allegation of abuse that she would be moved from her room, which greatly upset Resident #4 because she stated she helps her roommate and cares for her. Record review of the grievance logs for the facility revealed no grievance form was found for this resident despite her statement that she brought the issue to the ADM.

Based on observation, interview, and comprehensive record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #2) of the 10 residents reviewed for pain management. 1. The ADON and CNAs B and C failed to report Resident #2's pain during incontinent care to the resident's charge nurse. 2. The nurses failed to assess Resident #2's level of pain when she yelled. 3. The nurses failed to implement Resident #2's care plan for pain management. 4. The nurses failed to assess the effectiveness of Resident #2's pain medication. 5. The ADON failed to intervene and assess Resident #2 for pain during incontinent care. The ADON did not report pain to the nurse in charge following completion of care. Resident #2 yelled, grimaced, drew in her breath, and tightened up her legs during care. The resident was not treated for [REDACTED]. This failure affected 51 residents, receiving pain management at risk for unrelieved pain, delayed care, anxiety, and decreased quality of life. Findings included: Review of Resident #2's admission sheet, dated 09/14/14, revealed a current admission of 09/05/14. Review of Resident #2's (MDS) assessment dated [DATE] revealed [DIAGNOSES REDACTED]., Joint pain, Anxiety Disorder. Resident #2 was severely impaired for daily decision making and rarely/never understood. Resident #2 required extensive assistance to total care from two staff members for all ADLs. Resident #2 was on scheduled pain medication, received non-medication intervention, and received no as needed pain medication. Review of Resident #2's Care Plan dated 10/17/14 and revised on 04/10/15 revealed a potential for pain related to Resident #2 rarely never understood. The goal for the resident was to show no visible signs/symptoms of pain and the resident to be pain free as possible. The approaches/interventions outlined in the care plan included: 1) Assess resident for breathing changes 2) Assess resident for negative vocalization 3) Assess resident for changes in body language 4) ....Administer pain medication as ordered and as needed ... document effectiveness. 5) ....Assess for break through pain as needed when on routine pain meds. Resident #2's April 2015 Consolidated Physician order [REDACTED]. Resident #2's Pain Monitoring Sheet (PAINAID) for February 2015 reflected she did not exhibit any pain for 26 out of the 28 days documented. However, the Medication Tube Sheets reflected she received five doses of as needed pain medication, given by different nurses, with no follow-up to determine effectiveness. The resident also received nine doses of as needed anti-anxiety medication, given by different nurses, with no follow-up to determine effectiveness. Resident #2's Pain Monitoring Sheet (PAINAID) for March 2015 reflected she did not exhibit pain 31 out of 31 days she was monitored. However the Medication Tube Sheet reflected she received four doses of as needed pain medication, given by different nurses, with no follow-up to determine effectiveness. She also received five doses of anti-anxiety medication. Resident #2's Pain Monitoring Sheet (PAINAID) for April 2015 reflected she did not exhibit pain 14 out of the 14 days she was monitored. She was not given any does of as needed pain medication or anti-anxiety medication. Review of the Pain Monitoring reflected: monitor pain level every shift using the (PAINAID): 1. Breathing ... ...0-2 2. Negative Vocalization ....0-2 3. Facial Expression .....0-2 5. Body Language .....0-2 6. Consolabilty ......0-2 An observation on 04/14/15 at 7:30 p.m. revealed Resident #2 in a low bed, with a mat beside the bed. LVN A said Resident #2 had behavioral problems-she yelled all the time. LVN A said Resident #2 has yelled since the day she had admitted . An observation on 04/15/15 at 3:55 p.m. revealed CNA B and C repositioned Resident #2 to provide incontinent care; Resident #2 yelled, grimaced, tightened up her legs and arm, and ground her teeth. The facility's only ADON entered the room to pause the feeding tube pump, so the care could continue, stood in the room watched and listened as the resident exhibited symptoms of pain. CNA B and C repositioned Resident #2 to the opposite side, and she continued to yell and grimace, and drew in her breath. CNA B and C said to Resident #2, "it is okay honey, we will be done soon. We know." CNAs B and C completed the incontinent care and left the room. The ADON reset the pump and left the room. Resident #2 continued to yell. An interview on 04/15/15 at 4:15 p.m. with CNA B and C revealed when Resident #2 was hurting she yelled. Sometimes she yelled when she was wet and/or when she tried to talk to her family member. CNA B and C both agreed when they were perfroming incontinent care earlier, on 04/15/15, the resident was yelling in pain. CNA B and C said every time you had to move her she would yell. An interview on 04/15/15 at 4:45 p.m. with CNA B revealed she always reported to the nurse Resident #2's pain, but that time there was a nurse in the room and she thought that nurse told the resident's nurse. An interview on 04/15/15 at 5:00 p.m. with LVN A revealed Resident #2 had yelled since the day she had admitted to the facility. LVN A said they had a book for the pain assessment sheets. LVN A stated, "I do not know how you could assess her pain." She revealed staff reported yelling, but no pain. LVN A said the resident yelled all the time. An interview on 04/15/15 at 5:15 p.m. with LVN D revealed the pain assessment scale used was on the pain monitoring. LVN D said the nurse has to be able to recognize how to use these assessment tools. When asked about Resident #2, she replied she could pick a bunch of the characteristics, other than the (PAINAID assessment) on her; there are better scales to use on somebody like her. An interview on 04/16/15 at 8:00 a.m. with LVN E revealed Resident #2 received regularly scheduled pain medication. LVN E said she felt the pain assessment(PAINAID)used were hard to use on someone like Resident #2 to determine if there was pain or just behaviors. We do not have a follow-up sheet, we just wait until the end of our shift to document on the (PAINAID) the amount of pain the resident had. An interview on 04/16/15 at 1:20 p.m. with ADON revealed Resident #2 had been like this since the day she came to live here. The ADON said it is all behaviors all the yelling. She stated the resident stopped yelling when the staff finished her care. When asked about the pain during incontinent care, the ADON replied she got regular scheduled pain medication. When asked if she reported the pain the nurse in charge on 04/15/15 following the incontinent care, the ADON replied, " No because it is all behaviors. " An observation on 04/16/15 at 1:45 p.m. revealed Resident #2 in her room in her Geri -chair yelled out and grimaced. Resident #2 drew her legs up. An observation at that time revealed the ARN (Assistant Regional Nurse) spoke to LVN E. Then LVN E obtained her medication cart. Interview with LVN E at that time revealed the ARN told her to see why Resident #2 was yelling. LVN E said the resident was in pain because they got her up. LVN E gave Resident #2 some pain medication. LVN E said the resident yelled all the time, but if the staff had told her they were getting her up, she would have given the resident some pain medication. An observation on 04/16/15 at 2:15 p.m. revealed Resident #2 was comfortable, asleep in her Geri-chair, not yelling exhibiting no pain. An interview on 04/16/15 at 1:55 p.m. with CNA F revealed she always reported to the nurse in charge concerning any pain with a resident. CNA F stated, " Resident #2 yelled a lot, she is hurting, sometimes it makes me feel bad because I have to move her, if I just did not have to touch her I would be okay. " An interview on 04/16/15 at 2:05 p.m. with CNA G revealed she assists with Resident #2. CNA G said, "Resident #2 always yells out and makes ugly faces when staff moved her. I will tell the nurse, but they always tell me that they know and she gets medication already gets for the pain every day." An interview on 04/17/15 at 2:00 p.m. with Resident #2's primary care physician revealed he was unaware the facility nursing staff was not assessing pain appropriately. The physician said pain was very important to him and the staff must utilize the medications that are ordered an available. The physician said he was aware Resident #2 yells a lot, but was not aware the staff was not assessing and treating the yelling, if it was related to pain. The physician said he would have thought the nursing staff would just try and keep Resident #2 comfortable as possible and if she is yelling, just treat her. Review of the facility's current Policy/Procedure or Pain Management Program dated 01/21/08 revealed: "...Standard: 3. ....Qualified staff will utilize a Pain Assessment tool to evaluate patients/residents experiencing either acute or chronic pain ... 4. ....Qualified Staff will recognize that pain is a co-existing condition .... 5. ....Qualified staff will recognize that unrelieved pain has an enormous physiological and psychological effect on patients/residents, therefore, will effectively manage pain as an integral component of their care...." "...Guidelines: 3. ....Follow-up response to pain management intervention is documented ...." "...Process of Pain Assessment: 7. ....For those residents who have PRN (as needed) pain medication ordered ... administer the PRN pain medication ...you also need to initiate and complete the Pain Monitoring and Flow Sheet form ...." "...9. ....Best practice would suggest that you re-evaluate the resident after 45 (mins) to one hour to determine if the intervention has been effective and document the outcome on the Pain Monitoring and Flow Sheet form ... ....We use the PAINAD-Pain Assessment IN residents with Advanced Dementia ...." Facility's Form CMS-672, Resident Census and Conditons of Residents, signed by the DON on 04/14/15, revealed 51 residents on a pain management program.

Based on observation, interview, and record review, it was determined the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for two (Residents #12 and #13) of 13 residents reviewed for pain management. 1) Resident #12 was not properly assessed and provided with pain management when she continued to complain of pain, even after receiving pain medication. 2) Resident #13 was readmitted with a [DIAGNOSES REDACTED]. Resident #13 also had a Stage II pressure ulcer on the left heel. When staff positioned Resident #13 for wound care, she groaned and during wound care treatment, she continued to exhibit pain. Resident #13 was not properly assessed, treated, and provided with pain management prior to the wound care treatment. These failures caused Residents #12 and #13 to experience unnecessary pain and discomfort and placed them at risk for experiencing continuing, untreated pain, and no pain management. These failures could affect the 36 residents, who were on a pain management program, placing them at risk for not being assessed to ensure pain interventions being used provided pain relief and requests for pain relief were responded to in a timely manner, and residents were comfortable. Findings included: 1) Review of Resident's #12's Face Sheet dated 12/24/10 revealed a current admission date of [DATE] and diagnoses, which included: Pain in Limb, [MEDICAL CONDITION] and Dementia. Resident #12's most recent MDS assessment was a quarterly assessment dated [DATE]. The MDS assessment reflected the resident experienced pain almost constantly. The pain affected the resident's sleep and was a 10 on a 1 - 10 pain scale, with 10 being the worst pain. Resident #12 was initially observed during rounds on 05/02/11 at 9:50 a.m., sitting in a wheelchair in her room. The resident was complaining of pain. During this time, the resident stated she had received a pain pill, but it was not working, and it never worked. LVN B was informed of the resident's complaint of pain. An observation of Resident #12 on 05/02/11 at 1:45 p.m. revealed she was being assisted from her wheelchair to the bed. The resident stated, "I'm still hurting." She further stated the pain medication had not been effective. Resident #12 was queried about the nurse checking back with her after the medication was administered that morning. The resident stated no one had checked back to see if the medication had been effective from the previous observation. Review of Resident #12's monthly physician's orders [REDACTED]. The orders reflected the resident could have one tablet of [MEDICATION NAME] (narcotic pain medication) 7.5/325 mg orally every four hours as needed for pain. An interview with LVN P on 05/02/11 at 2:00 p.m. revealed she had administered one of the [MEDICATION NAME] 7.5/325 mg tablets to Resident #12 "earlier." LVN P was asked if the medication was effective. LVN P stated, "As far as I know." LVN P further stated the resident had not requested anymore pain medication. Review of Resident #12's PRN medication sheet revealed the only pain medication the resident had received was at 9:00 a.m. on 05/02/11 for complaints of pain in her feet and shoulders. The area on the medication sheet for documenting the effectiveness of the medication was blank. The pain monitoring sheet dated 05/02/11 and timed 9:00 a.m. reflected Resident #12 was experiencing feet and shoulder pain, which was scored at an intensity level of 7. According to the pain monitoring sheet, it was a Wong-Baker pain scale. (The Wong-Baker Pain rating shows a series of faces. The patient must choose the face, which best described how they were feeling.) However, there were no faces on the pain monitoring sheet or any explanation/description of a pain intensity level of 7. The pain scale on the pain monitoring sheet contained only six options: 0- No hurt, 2- Hurts little, 4- Hurts little more, 6- Hurts even more, 8- Hurts whole lot, and 10- Hurts worst. There was no 7 represented on the pain scale. An interview with Resident #12 on 05/02/11 at 2:30 p.m. revealed she occasionally requested pain medication from staff, but the medication did not work. According to the resident, facility staff never returned after administering the medication to assess for effectiveness. During this interview, the resident's family member was present and stated facility staff appeared insensitive to Resident #12's pain. The family member stated the resident had been expected to exercise and propel her wheelchair when she was in pain. Resident #12 nodded her head in agreement with the family member's statements. During an interview with LVN P on 05/03/11 at 9:45 a.m., she stated she assessed the effectiveness of pain medication usually "about two hours" after the medication was administered. LVN P stated Resident #12 complained of pain "all the time." LVN P further stated the physician did not believe the resident was experiencing pain. An interview with LVN P on 05/04/11 at 9:00 a.m. revealed Resident #12's physician had been notified, and an order was received to increase the pain medication. Review of Resident #12's most recent care plan revealed they had last been reviewed on 03/30/11. According to the care plan, interventions to address the resident's pain included assessing the location, frequency, duration and intensity of the pain. The care plan further reflected the assessment and effectiveness of pain medication would be documented, and increased pain trends would be reported to the physician. An interview with Resident #12 on 05/04/11 at 10:00 a.m. revealed she had no complaints of pain. The resident stated the "new medication" was much better. A physician's telephone order dated 05/04/11 reflected Resident #12's [MEDICATION NAME] had been increased to one and a half tablets of 10/325 mg every four hours as needed for pain. The order further reflected an appointment was to be obtained with a physician for pain management. The facility's undated P/P entitled "Pain Management" was provided by the Corporate Nurse on 05/04/11 and identified as current. According to the P/P, pain was considered the fifth vital sign and was whatever the experiencing person said it was. Qualified staff would utilize a pain assessment tool to evaluate resident's pain and develop a plan of care customized to the needs of each individual. Qualified staff would recognize that pain was a co-existing condition with a number of diseases and injuries and would require explicit attention. The P/P further reflected observations were critical to understanding both the cause of the resident's pain and the best way to manage it. Additionally, the P/P reflected caregivers should advocate for the resident in pain and never accept the explanation that pain was simply a part of getting old, even if the person saying this was the doctor. 2) Review of Resident #13's face sheet dated 12/03/08 revealed she was a [AGE] year-old female, admitted to the facility on [DATE] and readmitted on [DATE] and had [DIAGNOSES REDACTED]. Resident #13 was initially observed on initial tour on 05/02/11 at 9:15 a.m. lying in a low bed with a mat on the floor, her feet were "off loaded" on pillows, and there was a bandage on the left foot. An interview on 05/04/11 at 11:00 a.m. with CNA I revealed the resident required total care, except for eating. CNA I stated the resident was in the bed most of the time, since she had broken her leg and she could not move. An observation on 05/04/11 at 11:30 a.m. revealed LVN J and the facility's only ADON were in Resident #13's room performing wound care to her left foot. During the wound care process, Resident #13 exhibited pain by groaning, pulling her left foot back, shaking her left leg, then frowning and stating, "Ohh," when LVN J removed part of the dressing from the left foot. The ADON, noting the resident's pain, stated, "Would you like to squeeze my hand? We are almost done here." The ADON then stated to LVN J, "We should see about her pain medication," and then repeated to Resident #13, "We will see about your pain medication." An observation on 05/04/11 at 11:45 a.m. revealed the ADON was in the dining room instructing MA K to give Resident #13 pain medication. The ADON stated to MA K, "We just did her treatment and she is hurting." An interview on 05/04/11 at 11:50 a.m. with MA K revealed she was going to administer pain medication to Resident #13. When the surveyor queried how often MA K was instructed to give pain medication to Resident #13, MA K replied, "We used to give it often. None has been given recently." Review of Resident #13's physician's orders [REDACTED]. Resident #13's April 2011 MARs reflected no doses of [MEDICATION NAME] were given. The MARs also reflected one dose of [MEDICATION NAME] (narcotic/[MEDICATION NAME]) was given with no follow-up documentation concerning the medication's effectiveness. Resident #13's May 2011 MARs reflected no doses of Tylenol, [MEDICATION NAME] or [MEDICATION NAME] were given until 05/04/11. Review of Resident #13's "Pain Evaluation Form" dated 05/04/11 revealed the resident had diagnoses, which would give reason to believe she would be in pain. The [DIAGNOSES REDACTED]. Further review of Resident #13's "Pain Evaluation" revealed "PAINAD." Scoring included: Negative Vocalization, Facial Expression, Body Language, and Consolability. The resident scored a zero in each of these areas, despite the observation on 05/04/11 at 11:30 a.m. Resident #13's groaning should have scored one point; pulling her foot away should have scored two points; loud moaning should have scored two points; frowning should have scored one point and being reassured by voice or touch should have scored one point, giving her a total of seven points as opposed to the zero points she was assessed as having. Review of Resident #13's "Pain Evaluation Form" dated 05/04/11 revealed Resident #13 exhibited non-verbal signs of pain including: grimacing/distorted face, frowning/scowling, and/or fidgeting/irritability. Further review of the form revealed: "Conclusion: No pain, intervention is not necessary. Re-assess quarterly or with onset of pain ...monitor for signs of pain and updated pain meds as needed for any (increased) pain." Review of Resident #13's physician's telephone order dated 05/05/11 revealed, following surveyor intervention, "give pain medication one hour before treatment...." The facility's current undated policy on "Pain Management" reflected: Definition: "...Pain is whatever the experiencing person says it is, existing whenever the experiencing person say it does... Pain is considered the Fifth Vital Sign." "Standard: 1) Qualified staff will utilize a Pain Assessment tool to evaluate patients/residents experiencing either acute or chronic pain and develop a plan of care customized to the needs of each individual...." The policy did not reflect which tool to utilize or the parameters of time to utilize the Pain Assessment Form. "2) Qualified staff will recognize that pain is a co-existing condition with a number of diseases and injuries, and will require explicit attention... What is Pain?: 1) ...Your observations are critical to understanding both the cause of the resident's pain and the best way to manage it. Myth #1: If a resident is experiencing pain, he or she will tell us. Reality: 1) ...The resident is cognitively impaired and cannot communicate his or her pain in words. Myth #2 Sleep or sedation=pain relief Reality: 1) Pain is exhausting, and it depletes all of the body's energies, including the energy it needs to heal from what is causing the pain... What can I do as a caregiver? 1) Observe residents carefully for signs of pain. Some residents may not be able to verbalize pain; you may have to observe for behavioral symptoms. 2) Anticipate activities that might cause the resident some pain. If the resident has a prn prescription for pain medication, suggest taking the medication prior to these activities. Example - ...wound care. What about residents who cannot verbalize pain?" Further review of the P/P revealed "...examples are given of behaviors which can be indicative a resident may be in pain ...facial expressions, and increase/decrease in body movement...." The P/P for pain did not reflect guidelines on when to utilize the information given. Resident #13's "Fixed Care Plan" dated 03/30/11 reflected: Problem: Pain Goals: ...Resident will show no visible s/s of pain... Approach: 1) Assess location, ...per PAINAD pain scale. 2) Document assessment. 3) Administer pain medication ...per PAINAD scale. Document effectiveness. 4) Assess Resident for Physical Changes, ...pressure sores ...and/or previous injuries. 5) Assess resident for facial expressions. Resident #13's MDS assessment dated [DATE] reflected Resident #13 did not receive PRN pain medications. The MDS assessment was blank for staff assessment of vocal complaints of pain, non-verbal sounds, facial expressions, and protective movements/postures. Resident #13's MDS assessment dated [DATE] reflected Resident #13 did not receive PRN pain medication. The MDS assessment was blank for staff assessment of vocal complaints of pain, non-verbal sounds, facial expressions, and protective movements/postures. 3) The CMS form 672, Resident Census and Conditions of Residents, signed by the DON on 05/03/11, reflected 36 residents were on a pain management program. The census was 78.