Every finding on record at Franklin Heights Nursing & Rehabilitation

Based on interview and record review, the facility failed to ensure a comprehensive Minimum Data Set (MDS) assessment of each resident's needs, strengths, goals, life history, and preferences wasn't completed within the required 14-day timeframe following or 1 of 1 the quarterly assessment for resident reviewed (Resident #1). The facility failed to ensure the DOR completed Resident #1's BIMS assessment in a timely manner. The failure could place residents at risk of not having their needs met. Findings included: Record review of Resident #1's Face Sheet, dated 06/29/2026, revealed a [AGE] year-old male who was initially admitted to the facility on [DATE]. Resident #1's diagnoses included cerebral infarction, unspecified (a stroke caused by an interruption of blood flow to the brain); cognitive communication deficit (difficulty with thinking, understanding, and communicating); dysphagia (difficulty swallowing); anxiety disorder (a condition characterized by excessive worry or fear); vitamin D deficiency (low vitamin D levels that may affect bone health); flaccid hemiplegia affecting the right dominant side (paralysis or severe weakness of the right side of the body resulting from the stroke); unspecified protein-calorie malnutrition (poor nutritional status due to inadequate protein and calorie intake); dysarthria and aphasia (slurred speech and difficulty understanding or expressing language); personal history of COVID-19 (previous COVID-19 infection); schizoaffective disorder (a mental health disorder involving symptoms of schizophrenia and a mood disorder); chronic venous insufficiency (poor blood flow through the veins, typically affecting the legs); chronic viral hepatitis C (a long-term viral infection affecting the liver); hyperlipidemia (high cholesterol or elevated fats in the blood); other seizures (episodes of abnormal electrical activity in the brain); essential hypertension (high blood pressure); chronic embolism and thrombosis of an unspecified vein (long-term blood clots within a vein); gastroesophageal reflux disease without esophagitis (GERD, a condition in which stomach acid flows back into the esophagus causing heartburn); and presence of other heart-valve replacement (a surgically implanted artificial heart valve). Record review of Resident #1's MDS assessment dated on 06/12/2026 specifically the BIMS portion revealed resident required a Staff Assessment for Mental Status instead of the generalized BIMS assessment conducted. The Staff Assessment reflected that the resident had cognitive impairment, as evidenced by the resident's inability to complete the BIMS interview and the need for staff assessment to evaluate cognitive status. The assessment further reflected that the resident was able to recognize he was in a nursing home and identify the location of his room. Record review of Resident #1's comprehensive MDS assessment revealed the ARD was established beyond the required 14-day assessment period. Further record review revealed the comprehensive MDS assessment was initiated on 06/12/2026, and had not yet been completed exceeding the regulatory timeframe. Record review of Resident #1's comprehensive person-centered care plan revealed the resident's identified problem was impaired cognitive function and impaired thought processes related to impaired decision-making and cerebral infarction (stroke). The care plan established a goal for the resident to maintain his current level of cognitive function through the review date and included interventions such as administering medications as ordered, communicating with the resident and responsible party regarding the resident's capabilities and needs, and addressing concerns related to confusion, disease process, and nursing home placement.On 06/30/2026 at 2:32 p.m., an interview was conducted with the MDS Case Manager stated she had been employed at the facility for four months and had six years of experience completing MDS assessments. She stated she maintained an MDS schedule, reviewed open assessments weekly, encouraged staff to monitor assessment status daily, and reported interdisciplinary care plan meetings were conducted every Thursday. MDS stated case manager the ARD established the timeframe for completion of the comprehensive MDS assessment and development of the comprehensive person-centered care plan. She stated the comprehensive MDS assessment was required to be completed within 14 days of admission. The MDS Case Manager stated she had observed the DOR complete the BIMS while she completed other portions of the MDS assessment. She stated when more than one BIMS assessment was available with different scores, she utilized the assessment completed closest to the ARD. The MDS Case Manager stated significant differences in BIMS scores could affect the resident's care and reported she would follow up with the DOR or request a speech therapy evaluation to determine whether a change in the resident's condition had occurred. She further stated therapy had a process for completing cognitive assessments for nonverbal residents. The MDS Case Manager stated multiple assessments remained open and were not completed timely. She reported she routinely followed up with the DOR regarding incomplete assessments; however, communication barriers sometimes delayed completion of the required assessments. The MDS Case Manager confirmed Resident #1's comprehensive person-centered care plan was completed late due to the delayed completion of the comprehensive MDS assessment. She stated the delay had the potential to place the resident at risk because staff would not have timely access to an individualized comprehensive care plan to guide care based on the resident's current assessed needs.On 06/30/2026 at 2:37 p.m., an interview was conducted with the DOR, she had been employed as the facility's DOR since 04/06/2026. She reported she began completing the BIMS assessments in March 2026 and was unsure whether she had completed BIMS assessments prior to becoming the DOR working as a PRN COTA. The DOR described the process for completing a BIMS assessment. She stated she conducted the assessment in a quiet environment, such as the resident's room, to minimize distractions and promote the resident's ability to concentrate. She reported asking the resident to repeat three words and answer orientation questions regarding the date, time, and location. For residents with communication or cognitive impairments, DOR stated she attempted to write information for the resident to review and respond by nodding their head. If the resident continued to have difficulty completing the assessment, she stated she reviewed the resident's PHQ-9 to determine the resident's cognitive baseline. DOR stated she received training from the Regional Director on completing BIMS assessments, which consisted of one day of instruction and completion of one observed BIMS assessment. She reported she attempted to complete each BIMS assessment accurately by reviewing the MDS in progress, obtaining information directly from the resident, and documenting the resident's responses. The DOR stated she later learned that when a significant change in a resident's BIMS score was identified, she was expected to communicate the change to the nursing staff or the MDS department, although she was uncertain of the specific reporting process. On 06/30/2026 at 3:16 p.m., an interview was conducted with the Administrator, she said she was the immediate supervisor of the MDS department. She reported the facility utilized a QRM who communicated with the DOR regarding MDS processes, as the QRM served as the subject matter expert. The Administrator stated she monitored email communications regarding the DOR's responsibilities and any identified concerns. The Administrator stated the DOR had informed her at the beginning of her employment that she felt overwhelmed by the workload and requested guidance and assistance. The Administrator stated the DOR routinely attended interdisciplinary care plan meetings and was aware of residents requiring assessments and care plan development. The Administrator stated failure to complete required assessments timely could affect the accuracy and timeliness of documentation within the resident's medical record. She further stated the MDS Case Manager had informed her she was required to frequently remind the DOR of assessment deadlines. The Administrator stated she had been unaware the assessment deadlines were not being met and reported she would address the issue immediately. On 07/01/2026 at 11:55 a.m., an interview was conducted with the Regional Director, QRM who stated he had been onsite at the facility for approximately two to three weeks. He reported providing training to the current DOR, , for three days but was unable to recall the specific training dates. He stated the training included use of PCC, completion of UDAs, and management of assessment tasks. The Regional Director stated the DOR had been completing BIMS assessments prior to assuming the Director of Rehabilitation position. The Regional Director stated he directly observed DOR complete a BIMS assessment during the training period. He reported instructing DOR to communicate significant assessment changes to the nursing department; however, he clarified this instruction primarily pertained to changes identified through the PHQ-9 rather than the BIMS assessment. The Regional Director stated he was unable to explain the role of the BIMS assessment in the development of the comprehensive MDS assessment or how the comprehensive MDS assessment supported the timely development of the resident's comprehensive person-centered care plan. He stated the purpose of the BIMS assessment was to determine the resident's ability to communicate needs and participate in decision-making. The Regional Director reported he provided support to 17 facilities within company. He stated the Director of Rehabilitation training checklist was developed through a partnership between company and QRM and was used specifically to train Directors of Rehabilitation. On 07/01/2026 at 2:33 p.m., an interview was conducted with the DON, she stated she reviewed and signed the MDS assessments to ensure the assessments were completed accurately. She stated she monitored the completion of the assessments; however, she was unable to state the required timeframe for completion of the comprehensive MDS assessment. The DON stated she did not understand why multiple BIMS UDAs were being completed in the manner observed. She stated the DOR was responsible for completing the BIMS assessment. The DON reported that when the BIMS Version 2 interview could not be completed, the DOR was expected to initiate and complete the Staff Assessment for Mental Status. The DON stated qualified staff could complete assessments; however, the DOR was responsible for completion of the BIMS assessment. She stated she was unaware of the reason multiple BIMS UDAs were present for certain residents. The DON acknowledged that multiple or incomplete BIMS assessments could delay completion of the comprehensive MDS assessment and subsequently delay the timely development and implementation of the resident's comprehensive person-centered care plan. Record review of the facility's Nursing Policy and Procedure Manual, Policy AS 03-1.0, Resident Assessment, revealed the facility's policy required a comprehensive RAI assessment to be completed within 14 days of admission and annually thereafter. The policy further required the comprehensive assessment to include, but not be limited to, the resident's medical history, medical status, physical and mental functional status, sensory and physical impairments, nutritional status, psychosocial status, rehabilitation potential, cognitive status, and drug therapy. The policy further revealed the results of the comprehensive assessment were to be used to develop, review, and revise the resident's comprehensive person-centered care plan. Additionally, the policy required each assessment to be conducted or coordinated by a registered nurse, with each individual completing a portion of the assessment signing and certifying the accuracy of that portion of the assessment. The policy further required reassessments to be completed at prescribed intervals, with documentation of assessment findings and changes to the resident's plan of care reflected in the medical record and/or comprehensive care plan. Record review of the Creative Solutions Policy and Procedure, MDS Transmission, referencing the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Chapter 5, revealed all federally required MDS assessments were required to be electronically transmitted to the Centers for Medicare & Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. The policy further revealed comprehensive MDS assessments were required to be electronically transmitted within 14 days of the Care Plan Completion Date and required all federally mandated MDS sections, including the Care Area Assessment (CAA) Summary, to be completed in accordance with federal requirements. The policy further indicated transmission requirements applied to all MDS assessments used to meet federal and state requirements.

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident goals and preferences for 1 of 6 residents (Resident #1) reviewed for oxygen management. The facility failed to post an Oxygen sign that documented Resident # 1 received oxygen in her room on 03/27/2026. This failure could place residents at risk of receiving incorrect or inadequate oxygen support and decline in health and risk of fire hazards.Findings include: Record review of Resident #1's face sheet, dated 03/27/2026, revealed an [AGE] year-old female with an admission date of 07/21/2018.Record review of Resident #1's history and physical, dated 10/30/2025, revealed an [AGE] year-old female with diagnoses which included Alzheimer's disease (a progressive brain disorder that affects memory, thinking, and behavior), chronic obstructive pulmonary disease (COPD) (a chronic lung disease that makes it difficult to breathe), allergic rhinitis (inflammation of the nasal passages caused by allergies), and dementia (a decline in memory and cognitive function affecting daily life).Record review of Resident #1's annual assessment MDS ,dated 01/05/2026, revealed a BIMS score of 0, which indicated severe cognitive impairment. Section I Active Diagnoses, included Asthma (a condition where airways in the lungs become inflamed, narrow and sensitive making It harder to breathe), COPD, or Chronic Lung Disease.Record review of Resident #1's care plan, dated 01/13/2026, revealed interventions related to oxygen therapy, which included oxygen administration at 2 liters per minute via nasal cannula as needed for oxygen saturation at or below 90 percent, monitoring of respiratory status, and interventions to support adequate oxygenation. During an observation on 03/27/2026 at 11:29 a.m. in Resident #1's room revealed the resident was asleep in bed. She was wearing her nasal cannula, and her oxygen concentrator was turned on. There was no oxygen sign posted outside Resident #1's room. During an interview on 03/27/2026 at 11:28 a.m., CNA A stated an oxygen sign needed to be posted outside every room that had an oxygen concentrator inside. CNA A stated the potential negative outcome for a resident who had an oxygen concentrator inside their room and had no sign posted, could result in staff not monitoring the oxygen levels for a resident and not provide the necessary services for oxygen. CNA A stated there was a fire hazard if a resident or visitor went inside a room with a concentrator and if they had a lighter and they used it, it could potentially cause a fire in the room. During an interview on 03/27/2026 at 11:33 a.m., CNA B said the oxygen sign needed to be posted outside the room if the resident had an oxygen concentrator in the room regardless if they were using it or not and said the potential negative outcome could be a fire accident or the resident was not monitored for oxygen levels and care. During an interview on 03/27/2026 at 11:35 a.m. with LVN C, he stated oxygen signs always needed to be posted outside the door if there was a concentrator in the room. LVN C stated the potential negative outcome for not posting an oxygen sign outside a residents' room could result in the resident not being checked for oxygen levels and a potential for a fire hazard if someone who didn't know there was oxygen in use in the room brought in a lighter or something that could create a spark causing a fire. During an interview on 03/27/2026 at 11:48 a.m. with LVN D, she stated oxygen signs needed to be posted outside the residents' room so the staff were aware the residents received oxygen and said by not having an oxygen sign posted, staff could miss the room and miss to check for oxygen levels on the resident. LVN D stated there was also a fire hazard if a visitor went into the room with a lighter and they're not aware of there being oxygen in use. During an interview on 03/27/2026 at 12:59 p.m. with the SW, he stated the facility needed to have oxygen signs posted outside of the room of all residents who had oxygen therapy. The SW stated the potential negative outcome for not posting an oxygen sign could result in staff not checking the oxygen concentrators to make sure they were clean or to check if they needed water. The SW stated there was also potential for fire hazards if a visitor or a confused resident got ahold of a lighter and they initiated a spark; there could be a fire in the room affecting the resident and the roommate. During an interview on 03/27/2026 at 1:22 p.m. with the DON, she stated there should be an oxygen sign posted outside the room if there was oxygen in use in the room to make residents and visitors aware. The DON stated by not having an oxygen sign posted outside the room, staff or visitors would not know there's oxygen use in the room and they could not have the extra caution by making sure they did not create sparks with things like lighters, or the facility staff overlooked the room and did not check for oxygen levels for those residents who were in oxygen therapy, affecting their health. During an interview on 03/27/2026 at 1:49 p.m. with the Administrator, she stated oxygen signs needed to be posted outside of any room that had an oxygen concentrator. The Administrator said the purpose of an oxygen sign was to inform nursing staff the resident in the room had oxygen so they could follow up and check on oxygen levels according to the residents' care plan. The Administrator stated by not posting an oxygen sign outside the resident's room, it could delay supervision for residents who received oxygen. The Administrator stated there was a potential for fire hazards if a visitor went into the room and had a lighter and if they created a spark, it could catch fire harming the residents in the room. Record review of the facility's, undated, policies and procedures titled Oxygen Administration, read in part: Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) by cannula or facemask to treat hypoxemic conditions caused by pulmonary or cardiac diseases. O2 therapy is alsoprescribed to ensure oxygenation of all body organs and systems. The amount of oxygen by percent ofconcentration or L/min, and the method of administration, is ordered by the physician. Theadministration, monitoring of responses, and safety precautions associated with it are performed by thenurse. The nasal cannula delivers 22-40 % oxygen and is the most common, inexpensive, and easiestdevice to use. Common oxygen sources for long-term administration include cylinder (portable orstationary) or wall system near the resident's bed or concentrator. Procedure 11. Place NO SMOKING signs in area when oxygen is administered and stored. Store oxygen cannister in an area free of flammable substances. Avoid the use of electrical appliances in the area of oxygen use as well. If the facility is non-smoking, oxygen in use signs are not required on individual resident rooms.

Based on observation, interview and record review the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 6 residents (Resident #2) reviewed for call light placement. The facility failed to ensure call lights were in reach for Resident #2 on 03/27/2026. This failure could place residents by not having access to call for assistance resulting in needs not being met.Findings include:Record review of Resident #2's face sheet, dated 03/27/2026, revealed a [AGE] year-old male with an admission date of 02/05/2022. Record review of Resident #2's history and physical, dated 11/15/2025, revealed a [AGE] year-old male with diagnoses which included hypertension (high blood pressure), dementia (a decline in memory and thinking abilities affecting daily life), COPD (a chronic lung disease that makes it difficult to breathe),, coronary artery disease (narrowing of the arteries that supply blood to the heart), chronic kidney disease (long-term damage to the kidneys affecting their function), and history of falls.Record review of Resident #2's annual MDS, dated [DATE], revealed a BIMS score of 0, which indicated severe cognitive impairment, meaning the resident was unable to recall information or effectively participate in the interview. Section GG, Functional Abilities and Goals, documented Resident #2 required substantial/maximal assistance with toileting hygiene (needed extensive help with cleaning self after using the restroom), upper body dressing (needed help putting on or removing clothing above the waist), lower body dressing (needed help putting on or removing clothing below the waist), and transfers (needed significant help moving from one surface to another such as bed to chair).Record review of Resident #2's care plan, dated 03/20/2026, revealed interventions directing staff to ensure the call light was within reach and to instruct the resident to use the call light for assistance as needed.During an observation and interview on 03/27/2026 at 11:31 a.m. in Resident #2's room, revealed the resident was lying in bed, and his call light was on the floor towards his feet. Resident #2 was confused and was talking and saying words, but it was uncomprehensible. Resident #2 had his bed sheet on his hand and the only discernible words he talked in Spanish were cold during the night.During an interview on 03/27/2026 at 11:30 a.m., CNA A stated call lights needed to always be within the resident's reach so residents could request assistance if needed. CNA A stated all staff who worked directly with residents such CNAs, LVNs and RNs were responsible for checking all residents who were in their rooms, had their call lights within reach. CNA A stated if a resident did not have their call light within reach it could result in them not having access to services in a timely manner or that they could not ask for help when they needed assistance to transfer or toileting.During an interview on 03/27/2026 at 11:34 a.m., CNA B stated call lights needed to be within the residents reach when they were in their room so they could ask for help or assistance whenever they needed it. CNA B stated not having access to their call lights, residents could potentially try to get up on their own and fall to the floor which could result in injuries.During an interview on 03/27/2026 at 11:37 a.m., LVN C stated call lights needed to always be within the resident's reach while they were in their room. He stated by not having a call light within reach, the potential outcome could be that the residents did not receive assistance in a timely manner or if there was an emergency such as a fall, they would not be able to call for help for them to be assessed, creating delays in care for the residents.During an interview on 03/27/2026 at 11:49 a.m. with LVN D, she stated call lights needed to be close to the resident and within reach. LVN D stated all staff were responsible for checking and monitoring to ensure residents had their call lights within reach while they were in their rooms. LVN D stated if the residents did not have their call light within reach, it could potentially place residents at risk if they tried to get up to get help, they could potentially fall to the floor causing injuries. LVN D stated there could potentially be delays in care if the call light is not within reach and they couldn't ask for help or assistance from the staff.During an interview on 03/27/2026 at 1:25 p.m. with the DON, she stated the facility did not have policies and procedures for call lights. The DON stated call lights had to be within reach of the resident so the resident could call for assistance whenever they needed help or assistance. The DON stated if residents couldn't reach the call light, there was a potential to delayed care for the resident's treatment in a timely manner. The DON stated residents with balance issues and confusion could potentially try to get up on their own and fall to the floor which could result in injuries or hospitalization.During an interview on 03/27/2026 at 1:53 p.m. with the Administrator, she stated all RNs, LVNs and CNAs were primarily responsible for checking that residents had their call lights within reach. The Administrator stated the potential negative outcome for a resident not having their call light within reach, could result in the residents not being able to call staff for assistance which could delay treatment or addressing emergencies such as falls or helping to manage pain.Record review of an email received on 03/27/2026 at 12:21 p.m. Sent by the DON, the DON stated the facility did not have a policy on call lights.

Based on interview and record review the facility failed to ensure that it employed a qualified social worker on a full-time basis for one of one social worker positions reviewed for social services. The facility, which was licensed for 132 beds, failed to employ a qualified social worker on a full-time basis since 08/05/2025. This failure could place residents at risk of not having their psychosocial or discharge planning needs met. Findings included:During an interview and record review on 01/09/26 at 4:59 p.m., with the facility's administrator in the presence of the HR Coordinator, Social Worker B revealed that he was hired on 09/18/25. The administrator said, Social Worker B does not have a license and was scheduled to take his test on 01/30/25. The administrator said the previous Social Worker's last day of work was on 08/05/25.Record review of the Social Worker Job Description, signed by Social Worker B on 09/18/25, provided by the facility's administrator, revealed the following was non-exhaustive criteria related to the job of a Social Worker, and it was consistent with the business needs of the facility. These are legitimate measures of qualifications for a Social Worker and are related to the functions that are essential to the job of a Social Worker. Knowledge Base: A bachelor's degree in social work, or secondary education in social services and certification as a social worker designee may be substituted as appropriate. Long Term Care experience. Develops social histories of residents and develops a social assessment and care plan for each resident which identifies medically related social and emotional problems and needs.

Based on interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 7 of 10 employees (DON, CNA P, SW B, LVN D, LVN N, CNA L and RN O) reviewed for employee misconduct registry and nurse aide registry screenings; the facility failed to complete Criminal Check for 2 (LVN N and RN O) of 10 employees reviewed for criminal checks. The facility had failed to have copies of previous annual employee misconduct registry and annual nurse aide registry screenings for DON, CNA P, LVN D, LVN N, CNA L and RN O in their personnel files. The facility failed to have a dated initial EMR/NAR check for Social Worker B upon hire on 09/18/25.The facility failed to complete the annual EMR/NAR screenings on LVN Charge Nurse on 01/09/26 according to facility's policy.The facility failed to complete a Criminal Check on LVN N and RN O upon hire.This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. Findings included:During an interview and record review on 01/09/26 at 4:30 p.m. with the HR Coordinator in the presence of the administrator, said she had started working at the facility on 09/18/25 and the Corporate HR Resource Manager had assisted her to compile the employees Criminal Checks and EMR/NAR selected for personnel file review with the state surveyor, revealed the following:RN Charge Nurse O revealed a rehire date of 02/23/24: Interview on 01/09/26 at 4:46 PM with the HR Coordinator revealed she had not found the Criminal Check report for RN O in her office and/or her personnel file, to show that the Criminal Check was completed upon rehire on 02/23/24. Record review of the most recent EMR/NAR check revealed it was completed on 01/20/25 by the previous HR Coordinator. The HR Coordinator said she had not found another EMR/NAR report in the RN O's employee records and/or personnel file to show the EMAR/NAR check was completed annually.CNA P DOH: 01/30/2020. Review of the most recent EMR/NAR check was completed on 02/19/25 by the previous HR Coordinator. Interview on 01/09/26 at 4:52 PM with the HR Coordinator said she had not found the previous EMR/NAR check in the employee's records and/or personnel file for CNA P to show it was completed annually.Social Worker B DOH: 09/18/25. Record review of the initial EMR/NAR revealed it was not dated. Interview on 01/09/26 at 4:59 PM, with the HR Coordinator said, The EMR/NAR report is not dated because Tulip was down when the check was completed. I can provide you with the copy of the email sent to the facility, letting us know that Tulip was down on that day. I did not run another EMR/NAR check once Tulip was working.LVN Charge Nurse D revealed Rehired Date: 09/09/2025. Review of the EMR/NAR was completed on 01/09/25 by the previous HR Coordinator. Interview on 01/09/26 at 5:00 PM with the HR Coordinator said she had not found the previous EMR/NAR check in LVN D's, employee record/personnel file to show the EMAR/NAR check was completed annually.Director of Nurses DOH: 02/26/24. Review of the EMR/NAR revealed it was completed on 01/21/25 by the previous HR Coordinator. Interview on 01/09/26 at 5:15 PM, with the HR Coordinator said she had not found the previous EMR/NAR check in the DON's employee's records and/or personnel file to show it was completed annually.LVN Charge Nurse N Rehire Date: 12/01/2023: Interview on 01/09/26 at 5:39 PM, with the HR Coordinator revealed she had not found the Criminal Check report for LVN N in her office and/or her personnel file, to show that the Criminal Check was completed upon rehire. Review of the last Annual EMR/NAR for LVN N revealed it was completed on 01/21/25 by the previous HR Coordinator. The HR Coordinator said she had not found another EMR/NAR report in the LVN N's employee's records and/or personnel file to show the EMAR/NAR check was completed annually.CNA L DOH: 11/22/24. Review of the most recent EMR/NAR check was completed on 02/19/25 by the previous HR Coordinator. Interview on 01/09/26 at 5:53 PM with the HR Coordinator said she had not found the previous EMR/NAR check in the CNA L's employee records and/or personnel file to show it was completed annually.Record review of facility's policy on Abuse/Neglect revised 03/29/18 revealed that the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. Procedure A. Screening: Criminal History and Background Checks. The facility will conduct criminal background checks of all personnel in accordance with Texas Health and Safety Code, Chapter 250. The facility administrator will be responsible for ensuring compliance with the policy and Texas state law regarding criminal background checks. All potential employees will be screened for history of abuse, neglect or mistreating of elderly. The Human Resource Clerk will monitor completeness and status of the criminal history checks for the facility. A copy of the completed tracking form will be maintained in the facility file. Employees will be screened for abuse, neglect, and exploitation of the elderly by accessing the Employee Misconduct Registry by calling the Texas Department of Aging and Disability at [PHONE NUMBER]. The hiring authority is responsible for training an individual to complete misconduct registry checks on every employee.Record review of the facility's HR - Personnel Handbook dated 2019, provided by facility's administrator revealed, Employment Eligibility - All employment applicants must go through an eligibility screening process prior to being hired. This process includes the Office of Inspector General, Misconduct/Nurse Aide Registry, Company-Wide Do Not Hire List, Criminal History Database, and any licensure board associated with your credentialing requirements. This facility completes a comprehensive background check prior to offer of employment, annually following your hire and as needed for reported concerns that could impact the resident care or facility liability. I any of the above-mentioned database are not operational: the facility will follow the directive or recommendations by the respective authority for a resource to obtain the employability validation.

Based on observation, interview and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 5 (Resident # 2, Resident # 5, Resident # 6, Resident #7 and Resident #8) of 8 residents reviewed for accommodation of needs. The facility failed to ensure Residents #2, #5, #6, #7 and #8, had their call lights within reach.This failure could place residents at risk for not having their needs/preferences met.Findings included:1. Record review of Resident #2's admission Record, dated [DATE] revealed an admission date of [DATE] and re-admission date of [DATE].Record review of Resident #2's Physician's Progress Note, dated [DATE], revealed a [AGE] year-old male with medical history of diabetes mellitus (a chronic condition where the body does not produce enough insulin or cannot use insulin effectively), multiple CVAs (a stroke, causing blood flow to part of the brain gets cut off, starving brain cells of oxygen and causing them to die) with residual left sided weakness, mental illness (refer to health conditions that involve changes in emotion, thinking, or behavior), HTN (when the force of blood pushing against the artery wall is consistently too high, making the heart work harder and straining blood vessels, which increases the risk of heart attack and stroke), left below the knee amputation, status post right foot first toe amputation.Record review of Resident #2's Annual MDS Assessment, dated [DATE], revealed, clear speech, made self-understood, BIMS Summary Score 15 (cognitively intact), toileting substantial/maximal assistance, frequently incontinent of urine, incontinent of bowel, dependent with chair/bed transfer; limitation in range of motion on one side to upper/lower extremity; mobility device - wheelchair; CVA, arthritis; frequently had pain at numeric rating scale of 7 in a pain scale from 1-10, 10 being the worst pain.Record review of Resident #2's Care Plan, dated [DATE], revealed the resident incontinent of bowel and bladder, had a Cerebral Vascular Accident (Stroke), and ADL self-care deficit. The care plan revealed encouraged the resident to use the bell to call for assistance.Record review of Resident #2's Physician Order Summary Active Orders as of [DATE] revealed, Start Date: [DATE] OT for skilled services to include self-care, therapeutic exercises, wheelchair management, for generalized weakness. OT TX Order, dated [DATE], revealed ADL retraining to increase BUE strength, facilitate postural control, improve dynamic sitting balance, increase independence in functional transfer, and increase functional activity tolerance in order to increase independence in ADLs.Record review of Resident #2's Visual/Bedside electronic report revealed, Safety: Encouraged the resident to use bell to call for assistance.During an interview on [DATE] at 12:10 p.m., Social Worker B revealed Resident #2 was oriented to person, place, and time, required total assistance with ADLs, incontinent of bowel and bladder, required two people to turn & reposition in bed. He said the resident was able to use the call light for assistance.During an interview on [DATE] at 1:47 p.m. LVN Charge Nurse G, assigned to Resident #2 on the morning shift, revealed the resident was alert, oriented to person, place, and time, required assistance of two people to turn and reposition in bed, incontinent of bowel and bladder and used a disposable brief, and was able to use the call light to ask for assistance to use the urinal and/or bed pan. She said they were trained to keep call lights within reach and licensed staff randomly made rounds to check call lights were placed within residents reach. She said Resident #2 had paralysis to the left side of the body with a below the knee amputation to the left lower leg and limited range of motion to the right arm. She said the nursing staff were trained to place the call lights within reach, and all staff were responsible for checking the call lights to ensure they were always kept within reach. She said Resident #2 was occasionally confused and at times used the call light for assistance to turn & reposition in bed or to use the urinal and/or bed pan.During an observation and interview on [DATE] at 9:25 a.m., Resident #2 was lying in bed awake, with the head of the bed raised at approximately 45 degrees, the call light clipped to the side of the head of the bed on his right side. Resident #2 demonstrated to the state surveyor that he could reach the call light but had difficulty reaching the call due to limited movement to his right arm and could not see where the call light was clipped on the head of the bed. He said, It's hard to reach the call light at times, but I do not like for them to clip the call light to my gown because it pinches my chest when I move in bed. Resident #2 demonstrated to the state surveyor that he had paralysis on his left side and could not use his left arm. During an interview on [DATE] at 10:06 a.m., LVN MDS Nurse M revealed Resident #2 was oriented to person, place and recognized familiar faces. He said the resident was able to use his call light for assistance. He said nursing staff were trained to place the call lights within reach, and all staff were responsible for checking the call lights to ensure they were always kept within residents' reach.During a telephone interview on [DATE] at 12:56 p.m. CNA P revealed Resident #2 was oriented to person, place, and time, required total assistance with ADLs, required assistance of two people to turn and reposition in bed, was incontinent of bowel and bladder, used a disposable brief, and could use his call light to request assistance. She said the CNAs were trained to place the call lights within reach, and all staff were responsible for checking the call lights to ensure they were always kept within residents' reach.During an interview on [DATE] at 12:57 p.m., CNA L revealed Resident #2 was oriented to person, place, and recognized familiar faces. She said Resident #2 was able to use his call light for assistance. She said the nursing staff were trained to place the call lights within reach, and all staff were responsible for checking the call lights to ensure they were always kept within residents' reach.During a telephone interview on [DATE] at 1:25 p.m., CNA Q revealed Resident #2 was oriented to person, place, and time, required total assistance with ADLs, had paralysis on the left side, below the knee amputation on the left leg, required assistance of two people to turn and reposition in bed, was incontinent of bowel and bladder, used a disposable brief, and could use his call light to request assistance. She said the CNAs were trained to place the call lights within reach, and all staff were responsible for checking the call lights to ensure they were always kept within residents' reach.2. Record review of Resident #6's admission Record dated [DATE] revealed an admission date of [DATE].Record review of Resident #6's History & Physical, dated [DATE], revealed an [AGE] year-old female with a history of Parkinsons Disease (a brain disorder that makes it hard to control movements, causing symptoms like tremors, stiffness, slow movements, and balance problems because the brain does not produce enough dopamine, a crucial chemical for smooth motion. This is a progressive condition, causing symptoms to worsen overtime.), dementia (a general term for a group of brain disorders that cause a gradual decline in cognitive abilities such as memory, thinking, language, problem-solving, judgement, and orientation), arthritis (general term for joint pain or joint disease meaning inflammation or swelling in one or more joints causing pain, stiffness and reduced movement often impacting daily activities) and oriented to person.Record review of Resident #6's Quarterly MDS, dated [DATE], revealed clear speech, made self-understood, understood others, impaired vision, BIMS Summary Score three (cognitively severely impaired), incontinent of bowel & bladder, Non-Alzheimer's Dementia (losing the thinking, memory, and social skills enough to mess up daily life), Parkinson's Disease, cognitive communication deficit (difficulty with talking or understanding due to problems with thinking skills like attention, memory, problem solving or reasoning. Rather than a problem with the mouth or voice itself, often resulting from brain injury or conditions and affecting social interactions, organizing thoughts and following conversations).Record review of Resident #6's Care Plan, revised [DATE], revealed Resident #6 was incontinent of bowel and bladder, had Parkinson's Disease, alteration in musculoskeletal status r/t osteoarthritis (wearing out of the cartilage from age or use, causing bone to rub, leading to pain, stiffness, swelling, and grinding sounds, especially in hands, knees, hips, and spine, making movement difficult as it slowly breaks down the joint tissue over time) Interventions included anticipate and meet needs; be sure call light was within reach, encouraged the resident to use the call light and respond promptly to all requests for assistance. Resident #6 had impaired cognitive function r/t Dementia, had impaired vision, was ADL deficit, at risk for falls r/t difficulty in walking, muscle weakness, and Parkinson's (a brain disorder that makes it hard to control movements, causing symptoms like tremors, stiffness, slow movements, and balance problems because the brain does not produce enough dopamine, a crucial chemical for smooth motion. This is a progressive condition, causing symptoms to worsen overtime).During an observation and interview on [DATE] at 9:20 a.m., revealed Resident #6 was lying in bed eating breakfast. It was observed that the call light was clipped to the side of the pillowcase, slightly under the pillow and was not within reach of the resident. The resident was oriented to person, and place. Resident #6 said she used her call light for assistance. When the surveyor asked the resident if she could reach the call light, she said no. The resident said the staff usually clipped the call light next to the side of the bed close to her arm to be able to reach the call light to call for assistance.During an observation and interview on [DATE] at 9:23 a.m., Medication Aide J was in the hallway close to Resident #6's room. Med Aide J said Resident #6 was alert, oriented to person and place, and was able to use her call light for assistance. She said she administered Resident #6's medications at 9:00 a.m. that morning and had not noticed the call light was not within reach. Resident #6 was still eating her breakfast in bed. The Med Aide J placed the resident call light within reach by clipping it to the side of the bed, close to the resident's right arm. She said the nursing staff was trained to place the call lights within reach, and all staff were responsible for checking the call lights to ensure they were always kept within residents' reach.During an interview on [DATE] at 9:32 a.m., LVN N revealed Resident #6 was alert, oriented to person, place, and was confused at times. She said she did not know if the resident was able to use her call light. She said the resident yelled out when she needed help. She said, I check during rounds that call lights are kept within reach. She said she did not know who served the breakfast tray to Resident #6 this morning ([DATE]). She said the nursing staff were trained to place the call lights within reach, and all staff were responsible for checking the call lights to ensure they were always kept within residents' reach.During an interview on [DATE] at 10:08 a.m. LVN MDS Nurse M revealed Resident #6 was oriented to person and place. He said Resident #6 used her call light at times for assistance.3. Record review of Resident #5's admission Record dated [DATE], revealed an admission date [DATE] and re-admission date of [DATE]. Record review of Resident #5's Quarterly MDS, dated [DATE], revealed clear speech, usually makes self-understood, usually understood others, impaired vision, BIMS Summary Score six (cognitively severely impaired), independent with mobility, frequently incontinent of urine, occasionally incontinent of bowel, depression, diabetes mellitus, mood disorder, vascular dementia, and repeated falls.Record review of Resident #5's Care Plan, revised [DATE], revealed Resident has impaired cognitive function or impaired thoughts r/t Dementia. Resident had and Activities of Daily Living self-care deficit r/t to impaired cognition. Resident had a communication problem r/t cognitive impairment. Resident had hearing loss. Resident Was incontinent of bowel & bladder. Resident at risk for falls r/t muscle weakness, unsteady gait, incontinence and psychotropic medication use. Be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident required an antidepressant.During an observation and interview on [DATE] at 9:28 a.m., Resident #5 was lying in bed watching TV. It was observed that the call light was hanging on the wall on the call light plug in plate, by the head of the bed. The resident did not respond to questions and did not acknowledge that the state surveyor was talking to him.During an interview on [DATE] at 9:30 a.m. with CNA L revealed Resident #5 was able to use his call light for assistance. She said Resident #5 was oriented to person, place, and situation, ambulatory with a walker, and he did not like to use his call light and hang the call light on the wall. She said the nursing staff had been trained to place the call lights within reach, and all staff were responsible for checking the call lights were always kept within reach.During an observation and interview on [DATE] at 9:47 a.m. the Administrator revealed resident #5's call light was hung on the wall plug in plate by the head of the bed. She said the nursing staff were trained to place the call lights within reach, and all staff were responsible for checking the call lights to ensure they were always kept within reach.4. Record review of Resident #8's admission Record dated [DATE] revealed an original admission date of [DATE] and re-admission date [DATE].Record review of Resident #8's History & Physical, dated [DATE], revealed a [AGE] year-old male with medical history of hypertensive heart disease (damage from long-term high blood pressure, forcing the heart to work harder, causing the muscles to thicken, weaken or stiffen, leading to problems like heart failure, or heart attack), OCD (a cycle where unwanted, intrusive thoughts (obsessions) cause intense anxiety, leading to repetitive actions, or mental rituals (compulsions) performed to temporarily reduce that anxiety or prevent a feared outcome), vascular dementia (when brain function declined because of blood flow to the brain was reduced, often from strokes or damage vessels, depriving brain cells of oxygen and nutrients, leading to problems with memory, thinking, planning and judgment, with symptoms appearing suddenly or gradually depending on the damage's location and severity), multiple cerebral infarcts (several areas of the brain died due to a blocked blood supply, causing small strokes), orthostatic hypotension (a sudden drop in blood pressure when the person stood up from sitting down, causing dizziness, lightheadedness, or fainting because blood flow to the brain temporarily decreased), repeated falls, oriented to person. Record review of Resident #8's Quarterly MDS, dated [DATE], revealed clear speech, usually makes self-understood, usually understand others, BIMS Summary Score 0 (cognitively severely impaired), inattention, disorganized thinking, independent with mobility, occasionally incontinent of urine and bowel, hypertension, CVA (a stroke, causing blood flow to part of the brain gets cut off, starving brain cells of oxygen and causing them to die), vascular dementia, and OCD.Record review of Resident #8's Care Plan, revised [DATE], revealed Resident #8 had bowel and bladder incontinence r/t impaired cognition. Resident #8 had a stroke. Resident #8 had impaired cognitive function r/t dementia and an ADL deficit. Encouraged the resident to use bell for assistance. Resident #8 had depression and mood problems. Resident #8 was at risk for falls r/t weakness and poor balance. Be sure the resident's call light was within reach and encourage the resident to use it. The resident used antipsychotic medications.During an observation and interview on [DATE] at 9:36 a.m., Resident #8 was lying in bed awake. It was observed that the call light was hung on the wall plug in plate by the head of the bed. Resident #8 was alert, oriented to person and place. The resident was able to answer simple questions. The resident did not answer when the state surveyor asked him if he could use his call light for assistance.During an observation and interview on [DATE] at 9:45 a.m., the Administrator revealed Resident #8's call light was hung on the wall plug in plate by the head of the bed. She said the nursing staff were trained to place the call lights within reach, and all staff were responsible for checking the call lights to ensure they were always kept within residents' reach.During an observation and interview on [DATE] at 10:00 a.m., CNA S revealed Resident #8 was oriented to person and place and used his call light at times for assistance. She said she checked for call light placement at the start of the shift. She said, Today I was late to work, and did not check for call light placement when I arrived at work. She said the nursing staff were trained to place the call lights within reach, and all staff were responsible for checking the call lights to ensure they were always kept within reach.During an interview on [DATE] at 10:07 a.m., LVN MDS Nurse M revealed Resident #8 was oriented to person, place and recognized familiar faces. He said Resident #8 used his call light at times for assistance.During an interview on [DATE] at 3:43 a.m. with the Administrator said, she was informed by the facility's corporate staff that they did not have a policy on call lights.5. Record review of Resident #7's admission Record dated [DATE] revealed an admission date of [DATE].Record review of Resident #7's History & Physical, dated [DATE], revealed a [AGE] year-old male with medical history of vascular dementia (when brain function declined because of blood flow to the brain was reduced, often from strokes or damage vessels, depriving brain cells of oxygen and nutrients, leading to problems with memory, thinking, planning and judgment, with symptoms appearing suddenly or gradually depending on the damage's location and severity), DM (a condition where the body has too much sugar in the blood because it does not make enough insulin or could not use it well), CVA with right hemiplegia (paralysis on one side, caused by CVA (a stroke, causing blood flow to part of the brain gets cut off, starving brain cells of oxygen and causing them to die)), pleasantly confused, and noncompliant with other medical treatment.Record review of Resident #7's Quarterly MDS, dated [DATE], revealed clear speech, usually makes self-understood, usually understand others, BIMS Score 11 (moderate cognitive impairment), moderate assistance with toileting, partial/moderate assistance with sit to stand, chair/bed transfer, and toilet transfer, occasionally incontinent of urine, DM, Non-Alzheimer's Dementia (losing the thinking, memory, and social skills enough to mess up daily life), CVA with right hemiplegia.Record review of Resident #7's Care Plan, revised [DATE], revealed Resident #7 had a communication deficit. Resident #7 was diabetic. Resident #7 had hemiplegia r/t CVA. Resident #7 had a contracture (a permanent tightening and stiffening of muscles, tendons, skin, or other soft tissue that restricts normal movement of a joint, often due to scarring, from injury, disuse, or nerve damage) of the right hand. Resident #7 preferred call light to be placed in bedside drawers. Resident #7 had impaired visual function. Resident #7 had an ADL Self-Care deficit r/t Hemiplegia. Resident #7 at risk of falls r/t balance problems, hemiplegia. Be sure the resident's call light was within reach and encourage the resident to use it. During an observation and interview on [DATE] at 9:54 a.m., revealed Resident #7 was lying in bed watching TV. He was oriented to person, and place. It was observed that the call light was hung on the wall plug in plate by the head of the bed. He said, I am able to walk and do not use the call light for assistance.During an observation and interview on [DATE] at 9:54 AM with LVN Charge Nurse D assigned to Resident #7 on the day shift revealed, resident was oriented to person and place, recognized familiar people. He said Resident #7 used his call light at times for assistance with toileting. Upon entering Resident #7's Room with LVN D it was observed that the call light was hung on the wall plug in plate by the head of the bed. LVN D placed the resident's call light within reach. He said the nursing staff were trained to place the call lights within reach, and all staff were responsible for checking the call lights to ensure they were always kept within residents' reach. He said he checked for call light placement at the start of the shift and randomly during rounds.

Based on observations, interviews, and record review the facility failed to ensure resident was free from any physical or chemical restraints imposed for purposes of discipline or convenience for two (Resident #4 and Resident #5) of three residents reviewed for freedom from physical restraints. The facility failed to ensure Residents #4, and Resident #5 did not have pillows under their mattresses which restricted his movement from getting off the bed and were not required to treat his medical symptoms. This failure could put residents at risk of unnecessary restriction of their movements. Resident #4 Record review of Resident #4's face sheet dated 10/24/2025, revealed, admission on [DATE] to the facility. Resident #4 was a [AGE] year-old female diagnosed with Alzheimer's disease, abnormal posture and gait, neurocognitive disorder with Lewy bodies dementia (proteins that disrupt normal brain function), cognitive communication deficit (difficulties in communication), schizophrenia (brain disorder that affects how the brain processes information), major depressive disorder (sadness, hopelessness, and lack of activities), history of COVID-19 (Coronavirus, similar to a common cold, some cases can lead to respiratory distress), protein-calorie malnutrition (does not get enough protein and calories to maintain proper health), insomnia (lack of sleep), generalized muscle weakness (muscles can't work as hard as they should), anxiety (feeling of worry, nervousness, or fear), hypothyroidism (thyroid gland that does not make enough hormones), age related osteoporosis (bones that are weaker and more likely to break), hypertension (high blood pressure), peripheral vascular disease (circulation of the blood vessels), and Tourette's disorder (uncontrollable movement or sounds known as tics). Record review of Resident #4's admission MDS dated [DATE], revealed a severely impaired cognition BIMS score of 00 to be able to recall or make daily decisions. Functional abilities self-performance revealed extensive assistance (staff provides weight-bearing support assistance) for rolling left or right in bed, sitting to lying, lying to sitting on side of bed. Resident #4 was limited assistance (staff provided guided maneuvering of limbs or other non-weight- bearing assistance) for transfers from bed to chair, wheelchair, standing position. Record review of Resident #4's History and Physical, dated 07/08/2025, revealed, readmission to acute hospital secondary to a fall sustaining an acute fracture of the right femur neck (a hip fracture). Record review of Resident #4's care plan dated 05/19/2025, revealed, ADLs for bed mobility/transfers requiring supervision as needed. At a high risk for falls unaware of safety needs, ambulates without walker. Interventions to supervise closely and make regular compliance rounds whenever the resident was in room. Pillows were not care planned to prevent falls for Resident #4. Care plans had no medically needed devices indicating the Resident needed a pillow or device tucked into the bed sheet. During an observation and interview on 10/24/2025 at 10:00am, revealed Resident #4 was lying in bed. The surveyor went up to Resident #4 who was lying next to a long body pillow that was tucked underneath Resident's bed sheets. Attempted an interview with Resident #4 and the only response was hello. In an interview on 10/24/2025 at 10:09 am, CNA A stated she had been working at the facility for 9 months and worked the morning shift. CNA A stated she was trained on restraints. The last training was last month in September 2025 and was instructed not to add any barriers to Residents that don't allow them from moving freely especially Residents who were fall risk. CNA A walked to Resident #4's room where she witnessed the pillow tucked underneath the bed sheet and Resident #4 lying in bed. CNA A stated, The pillow is used to keep the resident from falling out of the bed because the resident is a constant mover and staff does not want the resident to fall. So, they either place a triangle holder but when staff do not have one, staff will add pillows. CNA A stated fall precautions used where the bed was to the lowest position, floor mats in place, and call lights in reach for all residents. In an interview on 10/24/2025 at 02:25pm the DON was presented with pictures showing Resident #4 with pillows tucked under her bed sheets. The DON stated that the procedure was used to be for repositioning the patient if medically needed. The DON stated that Resident #4 was still capable of getting out of her bed so the pillow being inserted under the bedsheet was not a restraint, but all staff took training on not inserting pillows under bedsheets. Resident #4 does not need any device or pillow for medical needs. In an interview on 10/24/2025 at 02:38 PM, LVN B stated she was the LVN and charge nurse and worked only Monday-Friday from 6AM-2pm. LVN B was shown a picture that had been taken by the surveyor during rounds showing the pillows tucked underneath the bed sheets of residents to prevent them from falling. LVN B stated that the picture showing the pillow tucked under the bed sheets was considered a restraint. LVN B stated that the facility had trained all staff not to do that (referring to the pillow put under the sheet), and it was not medically necessary. LVN B stated Resident #4 had no care plan in her records indicating a medical device, and Resident #4 had been able to ambulate on her own. LVN B stated she had never seen anyone perform this restraint before and did not know if it was something they did to try to keep the residents safe from falling out of bed. CNA's and LVN's, along with all nursing staff, were trained the same way and took responsibility for ensuring these restraints were not being used on residents. Charge nurses were responsible for verifying that these residents were not applied to residents. Charge nurses were also responsible for rounding on residents every 2-3 hours or more if needed. The risk for a resident having that type of restraint could be that the resident could have fallen over the pillow, resulting in a higher and potentially more severe fall. The resident could have become trapped between the wall or bed sheets such as a resident arm or torso, and that practice was not a safe or appropriate situation for residents from safely getting out of bed. A pillow tucked under the bed sheet was considered a restraint because it restricted the residents movement and limited their freedom to move or reposition themselves. Fall Interventions are low beds, floor mats, nurse rounds, CNAs also have documentation in PCC (an electronic health record system tailored for the needs of skilled nursing facilities) on what residents are labeled as a fall risk. In an interview on 10/24/2025 at 03:25 PM, LVN C stated she had worked at the facility for 16 years on the long-term side of the facility. LVN C stated staff had been trained not to place any type of devices or pillows underneath the bed sheets which were considered restraints. LVN C stated if a resident could not move the pillow or device, then it was considered a restraint. LVN C was shown the picture of Resident #4 with a pillow tucked under the bed sheets, and LVN C stated that it was indeed a restraint. LVN C stated staff were not trained to insert any type of pillow or devices under the bed sheets. LVN C stated that the ADON's and the charge nurses on the floors were responsible for overseeing that staff did not apply any of these restraints to the residents. LVN C stated the charge nurses mad sure they conducted rounds every couple of hours to ensure residents were receiving the care they needed. LVN C stated a resident could be at risk of being trapped between the wall or bed sheet and could sustain an injury. Resident #5Record review of Resident #5's face sheet dated 10/24/2025, revealed, admission on [DATE] and re-admission on [DATE] Resident #5 was a 90-[NAME] old male diagnosis with muscle weakness (muscles can't work making it hard to perform everyday activities), cerebral infraction (Stroke), dysphagia (difficulty swallowing), lack of coordination (uncontrolled movements or task), cognitive communication deficit (problems with communication), aphasia following cerebral infarction (difficult in communication after stroke), combined forms of age-related cataract, bilateral (in both eyes), acute myocardial infarction (heart attack), unspecified atrial fibrillation (irregular heartbeat), Dementia (affecting the memory), Alzheimer's disease (memory loss). Record review of Resident #5's history and physical dated 06/19/2025, revealed, readmission for Traumatic subdural hemorrhage (bleeding that occurs inside the skull) under total care skilled nursing.Record review of Resident #5's admission MDS dated [DATE], revealed, a severely impaired cognition BIMS score of 03 to be able to recall or make daily decisions. Functional limitation in range of motion revealed number 2 (impairment on both sides) on both upper extremity (Shoulder, elbow, Wrist, hand) and lower extremity (Hip, Knee, ankle foot). Functional abilities were all listed as 1 (Dependent - A helper completed all the activities for the residents. Helper does ALL the effort. Residents does none of the effort to complete the activity. Or the assistance of 2 or more helpers was required for the residents to complete the activity). The resident had a 0 (no) mark for no falls since admissions.Record review of Resident #5's care plan dated 09/16/2025, revealed that resident did not have any focus points on any fall hazards, goals or interventions. During an observation and interview with Resident #5, on 10/24/2025 at 04:53pm, revealed Resident #5 had bed at the lowest position as well as a floor fall mat and was lying at a 45-degree angle in bed. Resident #5 acknowledged the surveyor and stated that he was good. Resident #5 was not coherent and could not remember dates, times, or where he was. Resident # 5 was unaware of why there was a pillow shoved/propped under his bed sheet on his right-side shoulder. In an interview on 10/24/2025 at 03:39 PM, CNA D stated she had been employed at the facility for 18 years and works the morning shift from 6AM-2PM. CNA D stated she had received all training regarding restraints. She stated the training was provided by ADON's and DON's during which staff were instructed not to use pillows or devices for positing or prompting residents. A picture was shown to CNA D, and she stated that the pictures of Resident #5 were a restraint. Resident #5 could had been placed at risk by not being able to get out of bed as it restricts him from movement and reposition, and at risk of injury from attempting to get up or becoming trapped within the bed sheets and the wall. In an interview on 10/24/2025 at 04:23 PM, the Administrator stated that restraints were defined as anything that impeded a resident from performing an action. Pictures were shown to the Administrator, and she stated that if the item impeded the resident, then it was considered a restraint. The Administrator did not provide a direct yes or no answer when asked whether the pictures reflected restraints on residents. The Administrator was unable to identify specific risk on Resident #4 and Resident #5, and she continued to repeat that if it impeded the resident, then it was a restraint.Record review of the facility training dated 08/29/2025 titled Restraint Reduction in Nursing facilities revealed all staff had completed the training as it was a mandated course for September 2025.Record review of the facility's policy titled, Resident Rights, SS 03-09a revealed The resident has a right to be treated with respect and dignity including: 1. The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the residents' medical symptoms. Record review of the facility's policy titled, Nursing policy and procedure Manual; Abuse/Neglect revised 03/29/2018 revealed The resident has the right to be free from abuse, neglect, misappropriation of residents' property, and exploitation as defined in this subpart. This includes but was not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.Record review of the facility's policy titled, Restraint Mini Manual; Restraints, MM RE 03-3.0revealed, It is the policy of this facility to maintain an environment that prohibits the use of restraints for discipline or convenience.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs for 1 of 7 residents (Resident #1) reviewed for care plans.The facility failed to implement Resident #1's comprehensive person-centered care plan on 11/11/2025, for medication administration. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and not having personalized plans developed to address their needs.The findings included: Record review of Resident #1's face sheet dated 11/20/2025 revealed an [AGE] year-old male who was originally admitted to the facility on [DATE]. Record review of Resident #1's history and physical dated 7/5/25, revealed that Resident #1 was admitted to a local hospital on 06/18 with altered mental status and neglect concerns. Resident #1 was diagnosed with a left middle cerebral artery (MCA) stroke (blocked blood flow to the brain), urinary tract infection (infection of the urinary system), and metabolic encephalopathy (confusion due to infection and chemical imbalance). Due to dysphagia (inability to swallow safely), the resident underwent placement of a PEG tube (feeding tube placed directly into the stomach) on 07/03, which was required for enteral nutrition and medication administration due to unsafe oral intake. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 07, indicating moderately impaired cognition. Review of Section GG indicated the resident required substantial assistance with self-care and mobility and was dependent on staff for multiple activities of daily living due to limited physical and cognitive functioning. The MDS documented that the resident had impaired swallowing ability and required altered nutritional support due to his inability to safely swallow food or medications. The MDS Section K for swallowing and nutritional status, paragraph B reflected that the resident had a feeding tube, indicating that oral intake was not safe and that enteral feeding (providing nutrition, fluids and medications directly into the stomach or intestines through a feeding tube) methods were required. Record review of Resident #1's care plan dated 10/13/2025 revealed that the resident required tube feeding related to dysphagia (trouble with swallowing) and was dependent on a PEG tube (a tube placed through the belly into the stomach so a person can get food, water, and medications when they cannot safely eat or swallow by mouth) for nutrition, hydration, and medication administration. The care plan revealed that the resident was not safe for oral intake and required staff to administer feedings and medications through the PEG. The care plan directed staff to monitor tube placement, perform daily site care, keep the head of bed elevated during and after feedings, and monitor for complications including aspiration (when food, liquid, or saliva accidentally enters the lungs, which can cause choking), infection, tube dislodgement (when the feeding tube comes out of place or gets pulled out), and intolerance of feedings. In an interview on 11/19/2025 at 10:32 AM, Resident #1 stated a nurse had given him the wrong medication. Resident #1 stated that he did not know which medication it was, only that it was a white pill and a pink pill, and that the nurse placed the medication in his mouth for him to swallow. Resident #1 stated that his medications was supposed to be administered through his PEG tube per doctor's orders because it was not safe for him to swallow pills. The Resident said he told the staff he did not want the medications, but the nurse insisted he needed to take them, so he swallowed the pills. Resident #1 stated that after the staff gave him these medications, he reported the incident to a different nurse to make sure the right medications were being given to him. Resident #1 stated that after reviewing the medications he was supervised with, the nurse took him to the DON to report a medication error. Resident #1 stated that the staff monitored him for five days to make sure he did not develop complications from receiving the wrong medications. In an interview on 11/19/2025 at 10:55 AM with LVN A, he stated that when a resident is administered with medications by a CMA (certified medication assistant), the CMA is required to review the resident's medication orders and care plan to make sure they are following the physician's instructions. LVN A stated that failing to review a resident's care plan or medical record before giving medications could result in the resident receiving medications in a manner that is not consistent with their care needs. LVN A stated that not following a resident's care plan could lead to medication errors, a decline in the resident's condition, and the resident becoming ill if the wrong medications were given. In an interview on 11/19/2025 at 12:37 PM, the NP stated the medication error involving Resident #1 occurred because staff did not follow the resident's medication orders or his documented care plan. The NP stated that all CMAs, LVNs, and RNs was responsible for checking the resident's care plan before administering any medication to make sure the medication route and dosage matched the doctor's orders. The NP stated that the administered medication was an antiarrhythmic medication (a heart-rhythm-controlling drug) meant to lower the heart rate, and Resident #1 was not prescribed it. The NP stated that although the dosage was low, the resident was not supposed to receive that medication at all, and giving medications not listed on the care plan placed the resident at risk for changes in heart rate, blood pressure, or unexpected reactions. The NP stated that failing to follow the care plan was avoidable and could have resulted in a decline in the resident's condition if the wrong medications caused side effects or complications. The NP stated that he reminded staff of their responsibility to verify the care plan and orders each time medications was administered. Interviews were attempted on 11/20/2025 between 1:15 PM and 1:35 PM with CMA B to ask about the oversight on Resident # 1's review of his care plan that led to a medication error, but CMA B did not answer the phone. The investigator left a voicemail with identifying information, and a call back was requested. Phone calls were followed by a text message with identifying information requesting a call back, but CMA B did not contact the investigator. In an interview and observation conducted on 11/20/2025 at 1:30 PM, CMA C was observed administering medications for two residents. She explained that she followed procedures correctly by knocking on the resident's door, explaining the purpose of her visit, and assisting with required hygiene. CMA C stated she verified the 7 Rs (Right resident, Right medication, Right dose, Right route, Right time, Right reason, and Right documentation) before administering the medications. CMA C stated that CMAs was required to ensure the 7 Rs were always followed, and it was not acceptable to administer any medication that did not belong to the resident. She stated that failure to follow the 7 Rs could result in medication errors and potential harm to residents. In an interview on 11/20/2025 at 1:46 PM, the DON stated that all medication staff, including RNs, LVNs, and CMAs, was required to verify the physician's orders and the resident's care plan before administering any medications. The DON stated that staff was trained on medication pass and on the 7 rights of medication administration, which included confirming the right medication, route, dose, and resident. The DON said all staff are trained on these upon hiring and as part of their annual training. The DON stated she became aware that CMA B administer medications for Resident #1 that was not part of his care plan. The DON stated that CMA B later admitted she had given the resident pills, despite earlier denying it. The DON stated CMA B confused residents, resulting in one resident receiving the wrong medication. The DON stated the failure to follow Resident #1's care plan was avoidable and that staff are responsible for reviewing the plan before medication administration. The DON stated that not following a resident's care plan could lead to declines in health, including changes in blood pressure or heart rate, and adverse reactions if medications are given incorrectly. In an interview on 11/21/2025 at 11:23 AM, LVN D stated Resident #1 had a g-tube and was barely starting to eat orally and the facility had not transitioned him to oral medications. LVN D stated the resident asked if CMA B was going to give him his medications orally moving forward and she informed him no, that only the RN or LVNs was responsible for administering medications through the g-tube per the resident's care plan. LVN D reported that Resident #1 told her that CMA B had given him medications orally. LVN D stated she asked CMA B about this, and CMA B denied administering anything. LVN D said she explained to CMA B that she needed to know what the resident had taken so he could be safely monitored according to the care plan. LVN D stated she asked the resident again what he received, and the resident reported a white and a pink pill. LVN D stated she questioned CMA B again, but CMA B continued to deny administering medications. LVN D stated she reported the matter to the DON, who initiated the investigation. LVN D stated after she reported CMA B's failure to follow Resident #1's care plan, CMA B was immediately removed from the floor. LVN D stated she notified the nurse practitioner and the resident's family, who expressed no immediate concerns. LVN D stated that CMAs, LVNs, and RNs are responsible for following the resident's care plan and medication administration records (MARs) to ensure medications are administered safely and by the correct route. LVN D stated that the possible negative outcomes for not following a resident's care plan could result in medication errors, delay of treatments or harm due to incorrect medication routes. In an interview conducted on 11/21/2025 at 11:35 AM, the Administrator reported awareness that LVN D had notified the DON that Resident #1 stated he had received oral medications from CMA B, despite the resident having a g-tube and not being cleared for oral medication administration in his care plan. The Administrator stated the care plan clearly required medications to be given through the g-tube by an RN or LVN and that CMA B should not have administered any oral medications. The Administrator reported that CMA B initially denied administering any medications but that, after continued questioning, an investigation was initiated immediately. The Administrator confirmed CMA B was pulled from the floor and eventually terminated. The Administrator stated that all CMAs, LVNs, and RNs are responsible for following the care plan and MAR to ensure medications are administered exactly as ordered. The Administrator said the possible negative outcomes for not following a care plan could result in a resident being administered an incorrect dosage of medication, deterioration of medical conditions and hospitalizations. Record review of the facility's policy and procedure titled Comprehensive Care Planning, not dated, read in part: Care Plan Development Develop and implement a person-centered comprehensive care plan for each resident based on the comprehensive assessment findings (including the MDS). Include measurable objectives and timeframes that address the resident's medical, nursing, mental, and psychosocial needs. Ensure the care plan describes: - Services needed to attain or maintain the resident's highest practicable well-being. - The resident's rights, including the right to refuse treatment. - Specialized services or rehabilitative services. - The resident's goals for admission and desired outcomes. - The resident's preferences and potential for future discharge.Resident-Centered and Preference-Based Care Ensure care plans are person-centered and reflect the resident's goals, preferences, strengths, and needs. Engage the resident and/or resident representative during development of the care plan and document participation or reasons participation was not practicable. Address risks, needs, or declines in condition, and document the rationale for the facility's decisions.Interdisciplinary Team (IDT) Responsibilities Ensure care plans are developed and reviewed by an Interdisciplinary Team, including the attending physician, RN, nurse aide, and appropriate staff from relevant disciplines. Ensure the care plan is revised based on changes in the resident's goals, preferences, needs, or clinical status.Ongoing Review and Updating Review and revise the resident's care plan: - After each Admission, Quarterly, Annual, or Significant Change MDS assessment. - Anytime goals, preferences, or clinical needs change. - Based on changes in the resident's response to interventions. Documentation Requirements Document the comprehensive care plan in the medical record. Describe the resident's goals, preferences, strengths, weaknesses, identified needs, and planned interventions. Document the facility's efforts to educate the resident/representative regarding risks of refusing treatment and efforts to find acceptable alternatives. Ensure reasons for declining care or treatment and associated risks are documented in the care

Based on observation, interview, and record review, the facility failed to prevent significant medication errors for 1 of 7 residents (Resident #1) reviewed for pharmacy services. The facility failed to follow physician's order by administering Amiodarone (a heart medication used to control dangerous irregular heartbeats) to Resident #1 when he was not prescribed this medication. This failure placed the residents at risk of not receiving their medications as ordered by the physician, which could cause a serious allergic reaction and side effects.The findings included: Record review of Resident #1's face sheet dated 11/20/2025 revealed an [AGE] year-old male who was originally admitted to the facility on [DATE]. Record review of Resident #1's history and physical dated 7/5/25, revealed that Resident #1 was an [AGE] year-old male admitted to a local hospital on 06/18 with altered mental status and neglect concerns. Resident #1 was diagnosed with a left middle cerebral artery (MCA) stroke (blocked blood flow to the brain), urinary tract infection (infection of the urinary system), and metabolic encephalopathy (confusion due to infection and chemical imbalance). Due to dysphagia (inability to swallow safely), the resident underwent placement of a PEG tube (feeding tube placed directly into the stomach) on 07/03, which was required for enteral nutrition and medication administration due to unsafe oral intake. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 07, indicating moderately impaired cognition. Review of Section GG indicated the resident required substantial assistance with self-care and mobility and was dependent on staff for multiple activities of daily living due to limited physical and cognitive functioning. The MDS documented that the resident had impaired swallowing ability and required altered nutritional support due to his inability to safely swallow food or medications. The MDS Section K for swallowing and nutritional status, paragraph B reflected that the resident had a feeding tube, indicating that oral intake was not safe and that enteral feeding (providing nutrition, fluids and medications directly into the stomach or intestines through a feeding tube) methods were required. Record review of Resident #1's care plan dated 10/13/2025 revealed that the resident required tube feeding related to dysphagia and was dependent on a PEG tube (feeding tube placed directly into the stomach) for nutrition, hydration, and medication administration. The care plan documented that the resident was not safe for oral intake and required staff to administer feedings and medications through the PEG tube. The care plan directed staff to monitor tube placement, perform daily site care, keep the head of bed elevated during and after feedings, and monitor for complications including aspiration, infection, tube dislodgement, and intolerance of feedings. Record review of the facility's Employee Disciplinary Report dated 10/16/2025, revealed CMA B was placed on an investigatory suspension pending an investigation into allegations of administering Resident # 1 the wrong medication. The form was signed by the Human Resources staff and CMA B on 10/16/25. In an interview on 11/19/2025 at 10:41 AM Resident #1stated that a nurse had given him the wrong medication. Resident #1 stated that he did not know which medication it was, only that it was a white pill and a pink pill, and that the nurse placed the medication in his mouth for him to swallow. Resident #1 stated that his medications were supposed to be administered through his PEG tube per doctor's orders because it was not safe for him to swallow pills. The Resident said he told the staff he did not want the medications, but the nurse insisted he needed to take them, so he swallowed the pills. Resident #1 stated that after the staff gave him these medications, he reported the incident to a different nurse to make sure the right medications were being given to him. Resident #1 stated that after reviewing the medications he was supervised with, the nurse took him to the DON to report a medication error. Resident #1 stated that the staff monitored him for five days to make sure he did not develop complications from receiving the wrong medications. In an interview on 11/19/2025 at 10:55 AM, LVN A stated that CMAs (certified medication assistants) must verify a resident's medication orders before administering any medications to prevent medication errors. LVN A stated that reviewing the resident's care plan is also required to ensure medications are being given exactly as prescribed by following the seven R's that included the right dose, route, resident, medication, time and documentation. LVN A stated that when staff do not check the orders or the care plan, the risk of a medication error increases, which could cause the resident's health to worsen or make the resident sick if incorrect medication is administered. In an interview on 11/19/2025 at 12:37 PM, the NP stated that the resident experienced a medication error when he was given Amiodarone (a strong heart-rhythm medication used to treat dangerous irregular heartbeats) and Vitamin B12 (a vitamin used for anemia and nerve function), even though he was not prescribed either medication. The NP stated that Amiodarone can lower the heart rate and affect how the heart beats, and that giving it to someone who does not need it could cause dizziness, low blood pressure, weakness, or a dangerous change in heart rhythm. The NP stated the resident did not have any medical condition that would justify giving Amiodarone, making the error preventable. The NP stated he instructed the facility staff to check the residents' vitals throughout the day to make sure there were no negative reactions. The NP stated that all RNs, LVNs, and CMAs are required to verify the physician's orders before giving medications and that failing to do so places the resident at risk for harm. The NP stated that although the resident did not show an immediate reaction, the potential outcome of receiving unprescribed medications could have resulted in health complications such as dizziness, fainting and chest discomfort. Interviews was attempted on 11/20/2025 between 1:15 PM and 1:35 PM with CMA B to ask about the oversight on Resident # 1 review of his care plan that led to a medication error, but CMA B did not answer the phone. The investigator left a voicemail with identifying information, and a call back was requested. Phone calls were followed by a text message with identifying information requesting a call back, but CMA B did not contact the investigator. In an interview and observation conducted on 11/20/2025 at 1:30 PM, CMA C was observed reading the medication records for Resident # 2 and confirmed these medications were prescribed to the resident. CMA C explained to the investigator that CMAs need to confirm the seven Rs before supervising medications. CMA C stated that CMAs must never supervise medications to a resident if the medication was not ordered for them. CMA C stated that supervising the wrong medication such as Amlodipine to a resident who had not been prescribed with it could make the resident ill by lowering their blood pressure. She stated this could potentially result in injuries, dizziness, fainting, sickness, or hospitalization, depending on the resident's health condition. In an interview on 11/20/2025 at 1:46 PM, the DON stated she was notified that the CMA B had administered medications to Resident #1 that were not prescribed for him. The DON stated the incident involved Amiodarone (a heart-rhythm medication that slows the heart rate) and that the resident should not have been given any oral pills. The DON stated she immediately removed CMA B from the floor after learning that she confused residents while passing medications. The DON stated the physician was notified, and the Nurse Practitioner assessed Resident #1 to check for adverse reactions. The DON stated the resident's pulse was elevated due to anxiety but did not drop, and staff monitored his blood pressure for five days to ensure the medication error did not cause complications. The DON stated that administering unprescribed medications, especially Amiodarone, could cause a drop in blood pressure or heart rate, which could lead to health problems. The DON stated that RNs, LVNs, and CMAs are responsible for checking medication orders before administering any medications to prevent medication errors. Record review of the facility's in-services revealed that all staff from the facility had been trained on 10/16/25 by the DON on the 7 rights of medication administration, resident rights and Abuse Neglect and Exploitation. The DON stated that CMA B had been trained on all of these trainings upon being hired on April 7, 2023, and additionally, the DON had record of her observations of CMA B on 10/01/2025 where she had show proficiency on following the seven rights for medication administration, but CMA B had failed to comply with the training of the seven rights on 10/16/2025. In an interview on 11/21/2025 at 11:23 AM, LVN D reported that Resident #1 informed her he received medications orally from CMA B, specifically describing a white and a pink pill. LVN D stated the facility later identified that the medications involved were amiodarone, a medication used for heart rhythm problems such as atrial fibrillation (when the heart is beating out of rhythm), and vitamin B12, a nutritional supplement. LVN D reported that Resident #1 had a history of atrial fibrillation, and stated he was not at immediate risk from receiving amiodarone; however, she emphasized that he had no active order for amiodarone or oral medications at the time of the incident. LVN D reiterated that she questioned CMA B multiple times, but CMA B denied administering the medications. LVN D reported the incident to the DON and notified the NP and residents' family. LVN D stated that CMAs, LVNs, and RNs are responsible for verifying the MAR and prescriber orders before administering medications, ensuring accuracy, correct route, and resident safety. LVN D stated the potential negative outcomes from administering unprescribed or incorrect medications included allergic reactions, drug interactions, toxic effects due to unnecessary medications and hospitalizations. In an interview conducted on 11/21/2025 at 11:35 AM, the Administrator stated that the incident involved Resident #1 being administered oral amiodarone and vitamin B12 by CMA B, despite the resident not being prescribed those medications. The Administrator stated that Resident #1 reported receiving a white and a pink pill, which was later identified as those medications.The Administrator confirmed that amiodarone is a high-risk cardiac medication that should only be administered when prescribed and monitored. The Administrator stated that although the resident had a history of atrial fibrillation, he was not actively ordered amiodarone, making the administration a medication error. The Administrator emphasized that CMAs, LVNs, and RNs must always follow the MAR, check prescriber orders, and verify medication before administration, especially when supervising or administering high-risk medications. She stated the potential negative outcomes for administering amiodarone to a resident who did not need it could result in lowering the heard rate, dizziness and blood pressure drops which could complicate a residents' health. Record review of the facility's policy titled Medication Administration and General Guidelines, not dated, read in part: Medications be prepared, administered, and recorded only by licensed or otherwise legally authorized personnel who follow state regulations and facility procedures. Medications be administered exactly as ordered by the attending physician. If a dose appears incorrect, excessive, unclear, or inconsistent with the resident's condition, staff must contact the physician for clarification prior to administration. All current physician orders and medication schedules must be reflected on the resident's Medication Administration Record (MAR), and staff must verify each medication against the MAR before giving it. Staff must verify the identity of the correct resident using identification bands, photographs, the medical record, or verbal identification. Routine medications must be administered precisely as ordered, within one hour of the scheduled time, unless otherwise specified by the physician. If a medication is omitted, held, refused, or not given, staff must record the omission on the MAR, document the reason, and notify the physician as required. Staff must ensure the medication label matches the order on the MAR. If there is any discrepancy, unclear label, or questionable instruction, staff must not administer the medication until clarification is obtained. When medications require crushing, staff must follow manufacturer guidelines and ensure the MAR reflects that crushing is appropriate. Medications that are extended-release or enteric-coated must not be crushed. Staff must adhere to the Six Rights of Medication Administration:1. Right Dose2. Right Route3. Right Resident4. Right Medication5. Right Time6. Right Documentation

Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 7 (Resident #1) reviewed for pharmacy services. The facility failed to follow physician's order by administering Amiodarone (a heart medication used to control dangerous irregular heartbeats) to Resident #1 when he was not prescribed this medication. This failure placed the residents at risk of not receiving their medications as ordered by the physician, which could cause a serious allergic reaction and side effects.The findings included: Record review of Resident #1's face sheet dated 11/20/2025 revealed an [AGE] year-old male who was originally admitted to the facility on [DATE]. Record review of Resident #1's history and physical dated 7/5/25, revealed that Resident #1 was an [AGE] year-old male admitted to a local hospital on 06/18 with altered mental status and neglect concerns. Resident #1 was diagnosed with a left middle cerebral artery (MCA) stroke (blocked blood flow to the brain), urinary tract infection (infection of the urinary system), and metabolic encephalopathy (confusion due to infection and chemical imbalance). Due to dysphagia (inability to swallow safely), the resident underwent placement of a PEG tube (feeding tube placed directly into the stomach) on 07/03, which was required for enteral nutrition and medication administration due to unsafe oral intake. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 07, indicating moderately impaired cognition. Review of Section GG indicated the resident required substantial assistance with self-care and mobility and was dependent on staff for multiple activities of daily living due to limited physical and cognitive functioning. The MDS documented that the resident had impaired swallowing ability and required altered nutritional support due to his inability to safely swallow food or medications. The MDS Section K for swallowing and nutritional status, paragraph B reflected that the resident had a feeding tube, indicating that oral intake was not safe and that enteral feeding (providing nutrition, fluids and medications directly into the stomach or intestines through a feeding tube) methods were required. Record review of Resident #1's care plan dated 10/13/2025 revealed that the resident required tube feeding related to dysphagia and was dependent on a PEG tube (feeding tube placed directly into the stomach) for nutrition, hydration, and medication administration. The care plan documented that the resident was not safe for oral intake and required staff to administer feedings and medications through the PEG tube. The care plan directed staff to monitor tube placement, perform daily site care, keep the head of bed elevated during and after feedings, and monitor for complications including aspiration, infection, tube dislodgement, and intolerance of feedings. Record review of the facility's Employee Disciplinary Report dated 10/16/2025, revealed CMA B was placed on an investigatory suspension pending an investigation into allegations of administering Resident # 1 the wrong medication. The form was signed by the Human Resources staff and CMA B on 10/16/25. In an interview on 11/19/2025 at 10:41 AM Resident #1stated that a nurse had given him the wrong medication. Resident #1 stated that he did not know which medication it was, only that it was a white pill and a pink pill, and that the nurse placed the medication in his mouth for him to swallow. Resident #1 stated that his medications were supposed to be administered through his PEG tube per doctor's orders because it was not safe for him to swallow pills. The Resident said he told the staff he did not want the medications, but the nurse insisted he needed to take them, so he swallowed the pills. Resident #1 stated that after the staff gave him these medications, he reported the incident to a different nurse to make sure the right medications were being given to him. Resident #1 stated that after reviewing the medications he was supervised with, the nurse took him to the DON to report a medication error. Resident #1 stated that the staff monitored him for five days to make sure he did not develop complications from receiving the wrong medications. In an interview on 11/19/2025 at 10:55 AM, LVN A stated that CMAs (certified medication assistants) must verify a resident's medication orders before administering any medications to prevent medication errors. LVN A stated that reviewing the resident's care plan is also required to ensure medications are being given exactly as prescribed by following the seven R's that included the right dose, route, resident, medication, time and documentation. LVN A stated that when staff do not check the orders or the care plan, the risk of a medication error increases, which could cause the resident's health to worsen or make the resident sick if incorrect medication is administered. In an interview on 11/19/2025 at 12:37 PM, the NP stated that the resident experienced a medication error when he was given Amiodarone (a strong heart-rhythm medication used to treat dangerous irregular heartbeats) and Vitamin B12 (a vitamin used for anemia and nerve function), even though he was not prescribed either medication. The NP stated that Amiodarone can lower the heart rate and affect how the heart beats, and that giving it to someone who does not need it could cause dizziness, low blood pressure, weakness, or a dangerous change in heart rhythm. The NP stated the resident did not have any medical condition that would justify giving Amiodarone, making the error preventable. The NP stated he instructed the facility staff to check the residents' vitals throughout the day to make sure there were no negative reactions. The NP stated that all RNs, LVNs, and CMAs are required to verify the physician's orders before giving medications and that failing to do so places the resident at risk for harm. The NP stated that although the resident did not show an immediate reaction, the potential outcome of receiving unprescribed medications could have resulted in health complications such as dizziness, fainting and chest discomfort. Interviews was attempted on 11/20/2025 between 1:15 PM and 1:35 PM with CMA B to ask about the oversight on Resident # 1 review of his care plan that led to a medication error, but CMA B did not answer the phone. The investigator left a voicemail with identifying information, and a call back was requested. Phone calls were followed by a text message with identifying information requesting a call back, but CMA B did not contact the investigator. In an interview and observation conducted on 11/20/2025 at 1:30 PM, CMA C was observed reading the medication records for Resident # 2 and confirmed these medications were prescribed to the resident. CMA C explained to the investigator that CMAs need to confirm the seven Rs before supervising medications. CMA C stated that CMAs must never supervise medications to a resident if the medication was not ordered for them. CMA C stated that supervising the wrong medication such as Amlodipine to a resident who had not been prescribed with it could make the resident ill by lowering their blood pressure. She stated this could potentially result in injuries, dizziness, fainting, sickness, or hospitalization, depending on the resident's health condition. In an interview on 11/20/2025 at 1:46 PM, the DON stated she was notified that the CMA B had administered medications to Resident #1 that were not prescribed for him. The DON stated the incident involved Amiodarone (a heart-rhythm medication that slows the heart rate) and that the resident should not have been given any oral pills. The DON stated she immediately removed CMA B from the floor after learning that she confused residents while passing medications. The DON stated the physician was notified, and the Nurse Practitioner assessed Resident #1 to check for adverse reactions. The DON stated the resident's pulse was elevated due to anxiety but did not drop, and staff monitored his blood pressure for five days to ensure the medication error did not cause complications. The DON stated that administering unprescribed medications, especially Amiodarone, could cause a drop in blood pressure or heart rate, which could lead to health problems. The DON stated that RNs, LVNs, and CMAs are responsible for checking medication orders before administering any medications to prevent medication errors. Record review of the facility's in-services revealed that all staff from the facility had been trained on 10/16/25 by the DON on the 7 rights of medication administration, resident rights and Abuse Neglect and Exploitation. The DON stated that CMA B had been trained on all of these trainings upon being hired on April 7, 2023, and additionally, the DON had record of her observations of CMA B on 10/01/2025 where she had show proficiency on following the seven rights for medication administration, but CMA B had failed to comply with the training of the seven rights on 10/16/2025. In an interview on 11/21/2025 at 11:23 AM, LVN D reported that Resident #1 informed her he received medications orally from CMA B, specifically describing a white and a pink pill. LVN D stated the facility later identified that the medications involved were amiodarone, a medication used for heart rhythm problems such as atrial fibrillation (when the heart is beating out of rhythm), and vitamin B12, a nutritional supplement. LVN D reported that Resident #1 had a history of atrial fibrillation, and stated he was not at immediate risk from receiving amiodarone; however, she emphasized that he had no active order for amiodarone or oral medications at the time of the incident. LVN D reiterated that she questioned CMA B multiple times, but CMA B denied administering the medications. LVN D reported the incident to the DON and notified the NP and residents' family. LVN D stated that CMAs, LVNs, and RNs are responsible for verifying the MAR and prescriber orders before administering medications, ensuring accuracy, correct route, and resident safety. LVN D stated the potential negative outcomes from administering unprescribed or incorrect medications included allergic reactions, drug interactions, toxic effects due to unnecessary medications and hospitalizations. In an interview conducted on 11/21/2025 at 11:35 AM, the Administrator stated that the incident involved Resident #1 being administered oral amiodarone and vitamin B12 by CMA B, despite the resident not being prescribed those medications. The Administrator stated that Resident #1 reported receiving a white and a pink pill, which was later identified as those medications.The Administrator confirmed that amiodarone is a high-risk cardiac medication that should only be administered when prescribed and monitored. The Administrator stated that although the resident had a history of atrial fibrillation, he was not actively ordered amiodarone, making the administration a medication error. The Administrator emphasized that CMAs, LVNs, and RNs must always follow the MAR, check prescriber orders, and verify medication before administration, especially when supervising or administering high-risk medications. She stated the potential negative outcomes for administering amiodarone to a resident who did not need it could result in lowering the heard rate, dizziness and blood pressure drops which could complicate a residents' health. Record review of the facility's policy titled Medication Administration and General Guidelines, not dated, read in part: Medications be prepared, administered, and recorded only by licensed or otherwise legally authorized personnel who follow state regulations and facility procedures. Medications be administered exactly as ordered by the attending physician. If a dose appears incorrect, excessive, unclear, or inconsistent with the resident's condition, staff must contact the physician for clarification prior to administration. All current physician orders and medication schedules must be reflected on the resident's Medication Administration Record (MAR), and staff must verify each medication against the MAR before giving it. Staff must verify the identity of the correct resident using identification bands, photographs, the medical record, or verbal identification. Routine medications must be administered precisely as ordered, within one hour of the scheduled time, unless otherwise specified by the physician. If a medication is omitted, held, refused, or not given, staff must record the omission on the MAR, document the reason, and notify the physician as required. Staff must ensure the medication label matches the order on the MAR. If there is any discrepancy, unclear label, or questionable instruction, staff must not administer the medication until clarification is obtained. When medications require crushing, staff must follow manufacturer guidelines and ensure the MAR reflects that crushing is appropriate. Medications that are extended-release or enteric-coated must not be crushed. Staff must adhere to the Six Rights of Medication Administration:1. Right Dose2. Right Route3. Right Resident4. Right Medication5. Right Time6. Right Documentation

Based on interview and record review the facility failed to ensure the residents had information and contact information for State and local advocacy organizations including but not limited to the State Survey Agency and the State Long-Term Care Ombudsman program in a language understood for 7 of 7 residents (Confidential Group). The facility failed to ensure the Ombudsman information was reviewed with residents in the facility and ensure the information was discussed on how to file a complaint with the State agency when residents interviewed in a confidential group meeting were unaware, they had a Long-Term Care Ombudsman Program, contact information for the Ombudsman or how to file a complaint with the State agency. This failure could affect the residents who reside in the facility, to not be aware of resources that were available to them.Findings included: Record review of monthly resident council minutes for the last 6 months on 7/24/2025 at 8:40 am revealed no documentation of discussion regarding information on filing a complaint directly with the state agency or review of ombudsman information. In a confidential group meeting at 9:00 a.m., (7) residents present stated they did not know how to contact the ombudsman and how to file a complaint with the state agency. The residents agreed they were given a brief overview of the program and the name of the Ombudsman.During an interview with Administrator on 07/24/2024 at 3:30 p.m., revealed that upon admission the admission packet should have information regarding addressing concerns and grievance procedures. She stated that that when residents were admitted she introduced herself as administrator and as abuse coordinator and if residents or residents' families had any concerns, they could file a grievance directly with her, DON or any staff member that they voiced concerns with. She stated that she did not provide information verbally regarding filing complaints directly with the state, unless the family of resident voices that they do not wish to file the complaint with facility staff and wish to do it directly with the state, then the facility provides state number and ombudsman information. She stated that during resident council meetings the topic on state agency information was not discussed with residents as it was not a part of the checklist that corporate provides staff to use. During an interview with Activities Director on 7/24/2025 at 4:45 pm revealed that during resident council meetings, she goes through a checklist that touches on each department. She stated that if there were any concerns brought up during the meeting she was responsible for writing down the grievance and she has 3 to 5 days to resolve it. It was then brought up during the next meeting. She stated that the facility has ombudsman information posted in the entrance of the facility. She stated that residents and families could ask staff if they wanted the state number. She stated that the residents were verbally told that they had the right to file a complaint directly with the state if they wished to do so. She stated that she did not document that she verbally explained the process of contacting the state agency to file a complaint. Record Review of facility admission packet titled Health Care Center Policies, Information and Required Notices table of contents listed a section for policy for raising and addressing concerns grievance procedure, however, raising and addressing concerns grievance procedure section, was not covered in the facility packet and state agency number and ombudsman numbers were also not included.Record Review of resident rights policy revised on 11/28/2016 revealed The facility must provide a notice of rights and services to the resident prior to or upon admission and during the residents stay. The resident has the right to receive notices orally (meaning spoken) and in writing (including braille) in a format and a language he or she understands including, a list of names, addresses (mailing or email) and telephone numbers of all pertinent State regulatory and informational agencies. Resident advocacy group such as the State Survey Agency, the State licensure office, the state long term care ombudsman program, the protection and advocacy agency . A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding return to the community.

Based on observation, interview and record review, the facility failed to provide ADL care for 3 of 16 residents (Resident #56, # 94 and #107) reviewed for ADLs.-The facility failed to ensure Resident #56, # 94 and #107's fingernails were clean and free from debris on 07/21/2025.-This failure could place residents at risk of not having their personal hygiene needs met and cause low self-esteem.The findings include: Record review of Resident # 56's admission Record dated 7/23/2025 revealed a [AGE] year-old male with an initial admission date of 07/20/2020 and a readmission date of 08/19/2024. Record review of Resident # 56's health and physical dated 06/20/2025 revealed medical diagnosis of vascular dementia unspecified severity Record review of Resident # 56's quarterly MDS assessment dated [DATE] revealed a BIMS of 03 indicating severe cognitive impairment. Record review of Resident # 56's care plan dated 07/08/2025 revealed the resident had an ADL selfcare performance deficit related to muscle weakness, debility and unsteady gait/mobility and required 1 staff participation with personal hygiene and oral care. In an observation of Resident #56 on 07/21/2025 at 9:10am, the resident in the room was lying in bed. Some of his fingernails were observed to be long or chipped on hands bilaterally. Record review of Resident #94's admission Record dated 07/23/2025 revealed resident was a [AGE] year-old female with an initial admission date of 07/08/2022 and a readmission date of 07/26/2022. Record review of Resident #94's health and physical dated 08/01/2024 revealed medical diagnosis of Huntington's disease (inherited brain disorder that causes involuntary movements, cognitive decline and behavioral changes). Record review of Resident #94's quarterly assessment MDS dated [DATE] revealed BIMS of 06 indicating severe cognitive impairment. Record review of Resident #94's care plan dated 07/26/2025 revealed resident had an ADL self-care performance deficit calling for one staff participation with personal hygiene and oral care. In an observation and interview with Resident #94 on 07/21/2025 at 9:30 am, revealed resident with long dirty fingernails on both hands. She stated that staff did not cut them and that she would like them to cut them for her. Record review of Resident #107's face sheet dated 07/22/25 revealed resident was a[AGE] year-old male with an initial admission date 07/07/25. Record review of Resident #107's health and physical dated 07/07/25 revealed medical diagnosis of Unspecified Dementia with unspecified severity without behavioral disturbance, Diabetes Mellitus, hemiplegia (a condition characterized by severe or complete paralysis on one side of the body. This means a significant or total loss of muscle strength and control in the arm, leg, and sometimes the face on either the left or right side) and hemiparesis (a condition characterized by weakness or partial loss of strength on one side of the body) lack of coordination and inability to perform activities of daily living. Record review of Resident #107's admission MDS dated [DATE] revealed a BIMS score of 9 indicating moderate cognitive impairment. Section GG-Functional Abilities notated Resident #107 required substantial/maximal assistance and was dependent, meaning the helper does more than half or all the effort to complete activities.Record review of Resident #107's care plan revealed he had an ADL self-care performance deficit and called for staff to assist as needed with grooming, bathing, and personal hygiene. Interventions during bathing called to check for nail length and to trim and clean on bath day as necessary. In an observation and interview on 7/21/25 at 3:13 PM with Resident #107, revealed he was found lying in bed, watching TV, and eating cookies using his right hand. It was observed that he had long, yellowish fingernails with dirt and debris underneath them. Resident #107 stated that he was paralyzed from the left side of his body and could not move his arm, hand, leg, or feet. When asked if he preferred to have long fingernails, he stated he did not and had previously requested staff assistance to trim his nails several times, but no one had helped him.In an interview on 7/23/25 at 11:19 AM with CNA A, who stated the CNAs were able to assist residents with trimming their fingernails if they were not diabetic. She also stated that RNs and LVNs were able to assist residents if they observed them with long fingernails, and that it was all the staff's responsibility to check the resident's fingernails. CNA A said that if they detected a resident had long fingernails, they needed to report it to the charge nurse and then assist the resident with trimming the fingernails. CNA A stated the risk for a resident not having fingernails trimmed was that they could scratch themselves and open a wound which would lead to infection and make the resident sick.In an interview on 7/23/25 at 11:27 AM with LVN B, who stated that the nurses were responsible for assisting the residents with nail trimming. He stated that CNAs had more contact with the residents and were responsible for monitoring their hygiene in general and making sure their nails were trimmed. LVN B stated the risk for a resident having long and dirty fingernails could result in them getting an infection if they scratched themselves and opened a wound, and if their nails were contaminated with dirt, food residue or bodily fluids such as fecal matter if they had scratched themselves on their private parts.In an interview on 7/23/25 at 11:34 AM with LVN C, who stated that CNAs, LVNs, and RNs [BH2] were responsible for checking the resident's hands and ensuring their fingernails were trimmed and clean. LVN C said that only refusals were documented in the resident's progress notes in their health electronic records. LVN C explained there was a risk of infection if the residents' fingernails were long and dirty and if they touched their face and mouth. She added there was also a risk if they scratched themselves with dirty fingernails since they could open a wound on their skin which could lead to infection, bleeding, and sickness. LVN C said that a resident having long, and dirty fingernails could also impact their self-esteem and make them feel ashamed or that the facility did not care about them. In an interview on 07/24/2025 at 11:28 am with CNA D who stated that the importance of keeping resident fingernails clean was for their personal hygiene. She stated that the nurse was responsible for cutting residents' fingernails; CNAs are allowed to file them. She stated that she cleaned nails with a brush and water and reported that they needed trimming to the nurse. She stated that CNAs would check resident nails before showering them. She stated there have been Inservice on keeping resident nails clean. She could not remember the last Inservice. She stated that residents with long nails could scratch themselves and hurt themselves. In an interview on 07/24/2025 at 12:45pm with ADON who stated that long dirty fingernails could pose an infection control issue because residents touch their face. She stated that it was the responsibility of CNAs and nurses to try to keep up with fingernail trimming daily. She stated that the CNAs should've notified the nurses if residents needed fingernails trimmed, and CNAs were able to file them. She stated that there have been in-services pertaining to keeping resident nails clean and short, she could not recall date of last Inservice. In an interview on 07/24/2025 at 1:40pm with the DON who stated the importance of keeping resident nails clean and trimmed was to prevent infection and to keep residents from scratching themselves. She stated that the aids and nurses were responsible for ensuring that residents' nails were clean and trimmed. She stated that aids were responsible for trimming them. She stated that there have been in-services done pertaining to nail trimming; she could not recall the date of the last Inservice. In an interview on 07/24/2025 with Administrator at 2:45 pm stated, the CNA's and nurses were to ensure that nails were clean and trimmed. She stated that it was important to keep residents' fingernails clean and trimmed because residents touch food with their hands and put it in their mouths, they also touch their faces, and it could pose an infection control issue. She stated that she could not recall the last Inservice pertaining to nail care. Review of facility policy titled Nail Care Policy, not dated, read in part Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle are and is usually done during the bath. When performed at bath time, the nail care can be done following the procedure or as a separate procedure when needed at the convenience of the resident.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. -The facility failed on 07/21/2025 to seal a container with marinara sauce inside of refrigerator #1. -The facility failed on 07/21/2025 to maintain 1 strawberry ice cream container free from drippings in refrigerator # 3.-The facility failed on 07/21/2025 to close or seal a bag containing frozen egg omelets inside of refrigerator #4. -The facility failed on 07/21/2025 to dispose of rotting and moldy onions and potatoes in the pantry. These failures could place all residents who received meals from the main kitchen at risk of food borne illnesses.During observations on 07/21/2025 at 8:21 AM inside refrigerator #1, a container with marinara sauce was found not properly sealed with the lid not properly closed. At 8:23 AM, a tub of ice-cream was found inside refrigerator #3 that had dried and frozen drippings on its sides. At 8:29 AM a box with frozen egg omelets was found inside refrigerator #4. The box and the bag containing the frozen egg omelets was open and not sealed. At 8:32 AM, two rotten and moldy onions were found in the container with the rest of the fresh onions. At 8:33 AM, two moldy potatoes were found inside the box with the fresh potatoes. In an interview on 07/23/2025 at 8:21 AM with the Director of Food and Nutrition, stated that cooks were responsible for checking the pantries and fridges to ensure everything was clean, sealed, and free of rotting food. She explained the facility had a system in place where, at the end of their shifts, breakfast and evening cooks were required to check for spoiled or expired items and ensure everything was clean and sealed. The Director of Food and Nutrition said if an issue was found, it was expected for them to correct it by disposing the expired food. She said this was part of their cleaning duties worksheet, and they were required to check off that everything was clean. The Director of Food and Nutrition said staff would have been expected to conduct their daily checks on 7/20/25 after the evening shift was done. The Director of Food and Nutrition stated there was a potential risk of cross-contamination from open containers inside the refrigerator, bacteria and attracting pests from dry drippings, and rotten and moldy vegetables could contaminate other food and vegetables, potentially making residents sick. She stated that rotting vegetables could also potentially attract insects such as flies and cockroaches. In an interview on 07/23/2025 at 10:15 AM with the Dietary Supervisor who stated that everyone in the kitchen was responsible for checking that the food was dated, sealed, and containers inside the refrigerator were clean. The Dietary Supervisor said that it was her and the Director of Food and Nutrition's responsibility to check all recipients inside the refrigerators to ensure they were clean and sealed, and to dispose of any expired items or rotting and moldy vegetables. The Dietary Supervisor said she believed the facility did not have a system to track who was checking the refrigerators for cleanliness or for checking the pantries for expired or rotting food. The Dietary Supervisor stated that the risk for not properly sealing, closing, and cleaning containers inside the refrigerators when food was stored could result in cross-contamination and residents getting sick and there was also the possibility that they could attract pest such as insects. She stated that rotting food such as vegetables could create bacteria, spoil the rest of the vegetables, and potentially make residents sick if staff were to cook a meal with spoiled vegetables. In an interview on 07/23/2025 at 10:30 AM with a Dietary Cook, who stated that all staff were responsible for checking if containers were sealed and free of spills and drippings. If spills or drippings were present, staff needed to clean them, as the potential outcome was attracting insects, and serving food from unsealed containers could make residents sick. The cook also stated that the potential risk of having rotten vegetables mixed with other vegetables was for them to spoil the rest, and if food was prepared with rotten vegetables, there was a risk of making residents sick.In an interview on 7/24/25 at 3:32 PM, the Administrator stated that the kitchen staff had a cleaning list with tasks they were supposed to complete at the end of their shift. She said staff were trained annually through their computer system in everything related to cleaning and disinfecting the kitchen. The administrator said the Director of Food and Nutrition would be the person responsible for making rounds in the kitchen, ensuring there were no spoiled vegetables or expired food, and instructing staff to clean any containers that had dry drippings of food residues. She stated that the potential risk of having spoiled vegetables and open food containers could result in cross-contamination, which could make the residents sick. The administrator said that spoiled vegetables could create bacteria that would spoil other vegetables and could also potentially attract insects like roaches or flies, which carry diseases that could contaminate other foods and make the residents sick.Record Review of the form titled [NAME] Heights Cleaning Duties from July 20, 2025, to July 26, 2025, revealed the form had been initialed only by one staff member from the evening shift, indicating the blender, mixer and back wall had been cleaned. The form did not have times nor any other initials or information from other staff members.Record Review of the facility's policy dated 2012, titled Dietary Services Policy and Procedure Manual: Food Storage and Supplies, read in part: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin and insects. 0pen packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened.

Based on interview and record review the facility failed to have complete and accurately documented medical records for two (Resident #13 and #111) of five residents whose clinical records were reviewed for accuracy.-The facility failed to document room transfers and the reason for transfers for Resident #13 on 03/19/25 (Hall 4) and 06/27/25 (Hall 4 to Hall 1).-The facility failed to document room transfer and the reason for transfer for Resident #111's on 04/13/25 and 04/22/25.These failures could affect the residents in the facility at risk of inaccurate or incomplete clinical records. Findings included:Resident #13Record review of Resident #13's face sheet dated 07/22/25 revealed resident was a [AGE] year-old female with an admission date of 03/19/25.Record review of Resident #13's history and physical dated 04/22/25 revealed resident was legally blind and had medical history of physical debility (physical weakness, fatigue, or lack of energy that can impact daily functioning).Record review of Resident #13's quarterly MDS (Minimum Data Set) dated 06/22/25 revealed a BIMS (Brief Interview for Mental Status) score of 3, indicating severely impaired cognitive status.Record review of census per the facility's electronic charting system revealed Resident #13 was transferred to different rooms on 03/19/25 and on 06/27/25.Record review of Resident #13's progress notes dated 03/19/25 by LVN F revealed resident was admitted to the facility from a hospital and was verbally aggressive to the staff upon arrival. Progress notes did not notate verbal aggression to her roommate, Resident #13 requesting a room change, or that a room change occurred on 03/19/25, both rooms within Hall 4. Record review of Resident #13's progress notes dated 06/27/25 by LVN E called Responsible Party on 06/27/25 but there was no answer, and resident was transferred to another room, from Hall 4 to Hall 2. There was no documentation of the reason for room transfer, or that resident was given notice.Resident #111Record review of Resident #111's face sheet dated 07/24/25 revealed a [AGE] year-old female with admission date 02/04/25.Record review of Resident #111's history and physical dated 02/06/25 revealed medical diagnosis of Hypertension (high blood pressure), Diabetes Mellitus II (a chronic disease when a person has persistently high blood sugar levels), Acute Kidney Injury (sudden decrease in kidney function that can lead to the accumulation of waste products in the blood), and chronic kidney disease (a long-term kidney disease causing gradual loss of kidney function affecting kidney's ability to filter waste and excess fluids from your blood).Record review of Resident #111's quarterly MDS dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment.In an interview on 07/21/25 at 9:45 AM with Resident #13 who stated she had been transferred to different rooms twice and she stated she did not know the reason for the transfers.In an interview on 07/24/25 at 2:40 PM with Resident #111 who stated he transferred rooms on 04/13/25, both rooms in Hall 1, and transferred rooms on 04/22/25 to Hall 4.In an interview on 07/24/25 at 12:40 PM with the ADON who stated that Resident #13 was verbally aggressive to staff and residents that are not English speaking. She stated Resident #13 was transferred rooms on 03/19/25 because her roommate was not comfortable with Resident #13 since the roommate was primarily Spanish speaking. She stated Resident #13 was transferred rooms on 06/27/25 since resident was a skilled nursing resident and changed to a long-term resident. The ADON stated the CNA's, and Nurses were responsible for their progress notes ensuring accurate documentation. She stated herself and the DON were responsible for monitoring documentation on a daily basis.In an interview on 07/24/25 at 1:18 PM with the DON, who stated Resident #13 was transferred to another room on 03/19/25 because of aggression to her initial roommate. The DON stated Resident #13 transferred rooms on 06/27/25 because she became a long-term resident. She stated the nurse's progress notes did not reflect the room change on 03/19/25 and did not reflect Resident #13's request for the room transfers that day. She stated it should have been documented, and accurate documentation was the responsibility of the nurse adding the progress note. She stated herself and the ADON monitor progress notes for accuracy daily. She stated the lack of documentation was a risk for inaccurate treatment of the resident because behaviors or trends are not documented. In an interview on 07/24/25 at 3:15 PM with the Administrator who stated Resident #13 was transferred on 03/19/25 because Resident #13 was upset her roommate in Hall 4 spoke primarily Spanish. She stated Resident #13 was transferred to another room in Hall 4 that day she was admitted [DATE]. The administrator stated the reasoning for the transfers on 03/19/25 and 06/27/25, should have been documented by the nurses. The Administrator stated she reviewed Resident #13's progress notes and did not observe any notation regarding reason for room change for both mentioned dates. She stated the ADON and DON were responsible for monitoring nurses' documentation on a daily basis. The Administrator stated there was no written notice of room transfers for residents. In an interview on 07/24/25 at 4:22 PM with LVN E, who stated Resident #13 was transferred 06/27/25 from Hall 4 to Hall 2 because resident was changed from skilled resident to long-term resident. LVN E stated she was trained to document observations and any changes including the reason for room transfers. She stated she forgot to add reason for transfer on 06/27/25. LVN E stated the risk for residents of lack of documentation included miscommunication, and other staff will not be aware of resident changes. Record review of policy Documentation, with no date, read in part: Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident and or soft resident file. Goal: The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. Procedure: Complete documentation as needed in a timely manner. Each entry will be dated and timed. Documentation at least for 72 hours will be required for each shift for new admissions, during and following an acute episode, following an incident, and during psychological, mental, or emotional changes or instability.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 kitchen. -The facility failed on 07/21/2025 to effectively remain free of cockroaches in the only kitchen in the facility. These findings placed residents at risk of ill effects of pest infestation.During observation and interview on 07/21/2025 at 8:15 AM with the Director of Food and Nutrition, two dead cockroaches were observed on the kitchen floor in between cooking stations near a water drain. They were in near proximity to cooking utensils, pots and pans. The Director of Food and Nutrition stated that it was likely that cockroaches were present in the kitchen because it had been raining in the area and that made the insects crawl into the kitchen. The Director of Food and Nutrition stated that she would direct her staff to immediately clean and disinfect the kitchen floors. She stated the potential outcome of having insects in the kitchen could result in cross contamination which could lead to residents getting sick if the insect were in contact with food or the utensils used to prepare their meals. Record Review of the form titled [NAME] Heights Cleaning Duties from July 20, 2025, to July 26, 2025, revealed the form had been initialed only by one staff member from the evening shift, indicating the blender, mixer and back wall had been cleaned. The form did not have times nor any other initials or information from other staff members. In an interview on 07/23/2025 at 10:15 AM with the Dietary Supervisor who stated she had seen cockroaches before in the kitchen but as of late, due to the rain, she had seen cockroaches more frequently. She stated whenever she had seen roaches, she reported it to her supervisor or to the administrator. The Dietary Supervisor said she believed her supervisor had called pest control on Monday 7/21/25 for them to spray insecticide in the kitchen. The Dietary Supervisor said the expectation was for staff to sweep, mop, and disinfect twice in the morning and once in the evening or as required if the floor looked dirty. The Dietary Supervisor stated it was her and her supervisor's responsibility for checking that staff were cleaning and disinfecting the kitchen properly. She stated the risk of having insects such as cockroaches in the kitchen could result in cross-contamination and residents could get sick because their defenses were low. In an interview on 07/23/2025 at 10:30 AM with a Dietary [NAME] who stated staff were supposed to clean, sweep, and mop as needed if the floors were dirty and before they left their shift. The Dietary cook admitted she had not been signing off the Cleaning Duties sheet, because she got busy with other tasks such as preparing food for the residents. She stated the potential outcome of having insects in the kitchen could result in food being contaminated and making the residents sick.In an interview on 7/24/25 at 1:22 PM with the DON who stated she was the appointed Infection Control Preventionist for the facility. She stated that the facility had a contract with a company for pest control, and they went to the facility monthly to spray insecticides to prevent plagues and insects which could get the residents sick. The DON stated staff in the kitchen were expected to clean the kitchen every day at the end of their shift and as needed if there was a spill or something was dirty or became contaminated. She explained that cleaning entailed sweeping, mopping, and disinfecting the floors, making sure there were no food residues or crumbs on the floor, pantries, or refrigerators. The DON said staff were expected and instructed to report any presence of insects to their immediate supervisor, the administration, or herself. The DON stated that if staff found cockroaches in the kitchen, it was expected for them to immediately clean and disinfect the area. The DON said there was a potential negative outcome of residents getting sick if they consumed food that had been contaminated by insects such as cockroaches, and they could get gastrointestinal infections making them sick.In an interview on 7/24/25 at 3:32 PM, the Administrator who stated kitchen staff were expected to clean the kitchen at the end of every shift and as needed. The Administrator said the expectation was for staff to immediately clean and disinfect the area if they found dead insects such as cockroaches to prevent the spread of infection or cross contamination. The administrator said that staff needed to report any findings of insects or rodents to their supervisor immediately so that the pest control company could be contacted for them to service the facility and prevent residents' widespread sickness. She stated that the potential risk of cooking meals for the residents while insects were present in the kitchen could result in cross-contamination, which could make the residents sick. Record Review of the facilities policy dated 2012, titled Dietary Services Policy and Procedure Manual: Food Storage and Supplies, read in part: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin and insects. Insect and Rodent Control 2. Facility will maintain appropriate screens, close fitting doors, properly sealed water/sewer pipes, structurally maintained walls, baseboards, etc. to prevent entrance access of insects and rodents.33. Sanitation of facility will be maintained per other stated sanitation policies to prevent food sources, breeding places, etc. for insects or rodents.

Based on interview and record review, the facility to ensure resident's right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed for 3 (Resident #13, Resident #57, and Resident #111) of four residents reviewed for notification of room change. 1-The facility failed to provide written notice of room transfer on 03/19/25 and 06/27/25 to Resident #13 or their Power of Attorney (POA), 5 days' notice must be given to the resident or responsible party prior to the move.2-The facility failed to provide written notice of room transfer on 04/11/25 to Resident #57 or their Responsible Party, 5 days' notice must be given to the resident or responsible party prior to the move.3-The facility failed to provide written notice of room transfer on 04/13/25 and 04/22/25 to Resident #111, 5 days' notice must be given to the resident or responsible party prior to the move.These facility failures placed all residents at risk of being displaced without notice and/or reason in order to accommodate other individuals. 1-Record review of Resident #13's face sheet dated 07/22/25 revealed resident was a [AGE] year-old female with an admission date of 03/19/25. Face sheet revealed Resident #13 had a medical and financial POA.Record review of Resident #13's history and physical dated 04/22/25 revealed resident was legally blind and had medical history of physical debility (physical weakness, fatigue, or lack of energy that can impact daily functioning).Record review of Resident #13's quarterly MDS (Minimum Data Set) dated 06/22/25 revealed a BIMS (Brief Interview for Mental Status) score of 3, indicating severely impaired cognitive status.Record review of census per the facility's electronic charting system revealed Resident #13 was transferred to different rooms on 03/19/25 and on 06/27/25.Record review of Resident #13's progress notes dated 03/19/25 by LVN F revealed resident was admitted to the facility from a hospital and was verbally aggressive to the staff upon arrival. Progress notes did not notate Resident #13 requesting a room change, or that a room change occurred on 03/19/25, both rooms within Hall 4. Record review of Resident #13's progress notes dated 06/27/25 by LVN E called Responsible Party on 06/27/25 but there was no answer, and resident was transferred to another room on 03/19/25, from Hall 4 to Hall 2 on 06/27/25. There was no documentation of the reason for room transfer, or that resident was given notice.2-Record review of Resident #57's face sheet dated 07/24/25 revealed a [AGE] year-old male with initial admission date 04/19/24 and re-admission date 06/25/25. Face sheet revealed Resident #57 had a Responsible Party.Record review of Resident #57's history and physical dated revealed medical diagnosis of hypertension (high blood pressure), severe anxiety, and Dementia with behavioral disturbances (Dementia is a decline of cognitive function that affects daily life, including memory, reasoning, and language skills).Record review of Resident #57's quarterly MDS dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment.Record Review of facility's Action Summary dated 07/24/25 revealed Resident #57 was transferred to different rooms within Hall 1 on 04/11/25.3-Record review of Resident #111's face sheet dated 07/24/25 revealed a [AGE] year-old female with admission date 02/04/25. Face sheet revealed Resident #111 was her own Responsible Party.Record review of Resident #111's history and physical dated 02/06/25 revealed medical diagnosis of Hypertension (high blood pressure), Diabetes Mellitus II (a chronic disease when a person has persistently high blood sugar levels), Acute Kidney Injury (sudden decrease in kidney function that can lead to the accumulation of waste products in the blood), and chronic kidney disease (a long-term kidney disease causing gradual loss of kidney function affecting kidney's ability to filter waste and excess fluids from your blood).Record review of Resident #111's quarterly MDS dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment.Record review of facility's Action Summary dated 07/24/25 revealed Resident #111 was transferred on 04/13/25, both rooms within Hall 1, and 04/22/25, to Hall 4.In an interview on 07/21/25 at 09:45 AM with Resident #13 stated she had been transferred to different rooms twice and she stated she did not know the reason for the transfers. Phone call attempt made to Resident #13's POA, message and callback request left. POA had not returned call prior to exit.In an interview on 07/24/25 at 2:40 PM with Resident #111 stated she was not provided written notice for room transfer on 04/13/25, both rooms in Hall 1, and for room transfer on 04/22/25 to Hall 4.In an interview on 07/24/25 at 2:43 PM with Resident #57 stated he was not provided written notice for room transfer on 04/11/25, both rooms within Hall 1.In a telephone interview on 07/24/25 at 2:48 PM with Resident #57's Responsible Party (RP), who stated the RP was not provided a written notice of room transfer on 04/11/25.In an interview on 07/24/25 at 12:40 PM with the ADON who stated that Resident #13 was verbally aggressive to residents that are not English speaking. She stated Resident #13 was transferred rooms on 03/19/25 because her roommate was not comfortable with Resident #13 since the roommate was primarily Spanish speaking. She stated Resident #13 was transferred rooms on 06/27/25 since resident was a skilled nursing resident and changed to a long-term resident. She stated Resident #13 had a Power of Attorney and she was unable to recall obtaining consent for immediate room transfers on 03/19/25 and 06/27/25. She stated she was not aware of the 5-day notification for room transfers. She stated the Social Worker was responsible for room transfer notification. The ADON stated room transfers without notification could place residents at risk for confusion or agitation due to sudden environment change.In an interview on 07/24/25 at 12:49 PM with Social Worker who stated she was not involved with room transfers or notification to residents or their Responsible Party (RP). She stated nursing was responsible for room transfers. The Social worker stated she was not aware of the 5-day notification for room transfers. The Social Worker stated she did not inform Resident #13, or their RP of room transfers during her stay. The Social Worker stated she did not provide any residents and/or their Responsible Party of room transfers.In an interview on 07/24/25 at 1:18PM with the DON who stated Resident #13 was transferred to another room on 03/19/25, both rooms in Hall 4, because of aggression to her initial roommate. The DON stated Resident #13 transferred rooms on 06/27/25, from Hall 4 to Hall 2, because she became a long-term resident. She stated nursing staff was responsible for room transfer notification. The DON stated self and the ADON failed to notify the residents of their room transfer with the 5-day notice. She stated if written notices for room transfers were provided to the residents, the facility would have copies. DON stated it was not done and could not provide a reason written notices were not provided.In an interview on 07/24/25 at 3:15 PM with the Administrator who stated Resident #13 was transferred on 03/19/25 because Resident #13 was upset her roommate in Hall 4 spoke primarily Spanish. She stated Resident #13 was transferred to another room in Hall 4 that day she was admitted [DATE]. She stated she was not familiar with the 5-day notification or written notice for room transfer. She stated she was not sure why Resident #57's RP was not notified of room transfer prior to change and his RP was involved in Resident #57's care. The Administrator stated there was no written notice of room transfers for residents. She stated the ADON and DON were responsible for room transfers. The Administrator stated she did was not sure how room transfers without notification could affect the residents.Record review of facility's policy Room Changes dated 07/11/25, read in part: -If a resident is asked to relocate to another room, 5 days' notice must be given to the resident or responsible party prior to the move. The resident or responsible party can waive the 5 days and move earlier. -The notice must be in writing and include the reason for the changes.

The findings included:An observation and interview on 07/23/25 at 11:55 AM with Treatment LVN, revealed red dried drippings on the Betadine bottle stored in the treatment cart. Treatment LVN stated all bottles should be clean and free of dried drippings. He stated dried drippings were an infection control issue which can affect the residents. Treatment LVN stated he was responsible for the maintenance of the treatment cart.An interview on 07/24/25 at 12:25 PM with the ADON who stated the Treatment LVN was responsible for the treatment cart. She stated the Treatment LVN were to review their treatment cart daily for cleanliness including bottles being free from dried drippings. The ADON stated it was her and the DON's responsibility to monitor all carts for cleanliness on a weekly basis. The ADON stated the risk for dried drippings on the Betadine bottle included an infection control issue which was a risk for the residents being treated.An interview on 07/24/25 at 1:16 PM with the DON who stated that the Betadine bottle should be clean. The DON stated she was also the Infection Preventionist. She stated dried drippings were potential for bacteria accumulation which can cause the bottle to be contaminated. The DON stated the Treatment LVN was responsible for the cleanliness of their Betadine bottle stored in the treatment cart. She stated the Treatment LVN was to monitor their treatment cart daily throughout their shift while providing treatment. She stated herself and the ADON were responsible for monitoring all carts every 2 weeks.Record Review of policy Medication Carts, with no date, read in part: The medication carts shall be maintained by the facility, carts should be cleaned.The findings included:An observation and interview on 07/23/25 at 11:55 AM with Treatment LVN, revealed red dried drippings on the Betadine bottle stored in the treatment cart. Treatment LVN stated all bottles should be clean and free of dried drippings. He stated dried drippings were an infection control issue which can affect the residents. Treatment LVN stated he was responsible for the maintenance of the treatment cart.An interview on 07/24/25 at 12:25 PM with the ADON who stated the Treatment LVN was responsible for the treatment cart. She stated the Treatment LVN were to review their treatment cart daily for cleanliness including bottles being free from dried drippings. The ADON stated it was her and the DON's responsibility to monitor all carts for cleanliness on a weekly basis. The ADON stated the risk for dried drippings on the Betadine bottle included an infection control issue which was a risk for the residents being treated.An interview on 07/24/25 at 1:16 PM with the DON who stated that the Betadine bottle should be clean. The DON stated she was also the Infection Preventionist. She stated dried drippings were potential for bacteria accumulation which can cause the bottle to be contaminated. The DON stated the Treatment LVN was responsible for the cleanliness of their Betadine bottle stored in the treatment cart. She stated the Treatment LVN was to monitor their treatment cart daily throughout their shift while providing treatment. She stated herself and the ADON were responsible for monitoring all carts every 2 weeks.Record Review of policy Medication Carts, with no date, read in part: The medication carts shall be maintained by the facility, carts should be cleaned.

Based on observation, interviews and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Residents #10) of 6 residents reviewed for call light placement. -The facility failed to ensure that Residents #10's call light was within her reach. This failure placed residents at risk of not being able to call for assistance when needed. Findings included: Record review of Resident #10's Admission Record dated 08/07/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #10's diagnoses included cerebral palsy (congenital disorder of movement, muscle tone, or posture), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), mild intellectual disabilities (deficits in theoretical thinking/learning), paraplegia (paralysis that affects your legs, but not your arms) and contracture of muscle, right hand. Record review of Resident #10's quarterly MDS dated [DATE], revealed a BIMS score of 01 indicating severe cognitive impairment. Resident #10 had impairment to both sides of her upper and lower body. Resident #10 was dependent on staff assistance with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, and transferring. Record review of Resident #10's care plan dated 08/07/2024, read in part Resident #10 had communication problem related to impaired cognition Cerebral Vascular Disease. Part of the interventions included Ensure/provide a safe environment: Call light in reach. Another focus area reads in part that Resident #10 had potential fluid deficit related to physical limitation. Part of the intervention included Keep fluids at bed side and offer fluids as much as possible. Resident #10 needs assistance with fluid intake in order to meet daily requirements. During an observation and interview on 08/06/2024 at 10:42 a.m., Resident #10 was lying in bed with her call button clipped onto the cord near the call light outlet. Resident #10's cup of water was on top of dresser approximately three feet away from the resident. Resident #10 said she could not reach the call button to call for help because her hand was contracted. Resident #10 said she was able to press the call pad button when she needed assistance, but someone left the button out of her reach. Resident #10 said she needs staff assistance when she wants water but could only do so using her call button which she could not reach. Resident #10 said the water was not within her reach. Resident #10 said she was given a shower in the morning and the staff returned her to bed and left her call button out of her reach. Resident #10 said she did not know how long the button had been out of her reach. During an observation and interview on 08/06/2024 at 10:44 a.m., LVN C entered Resident #10's bedroom and said Resident #10 had just been showered about 20 minutes before. LVN C said the CNAs brought Resident #10 back to her room and must have left the call button out of her reach. LVN C said Resident #10 was not in any distress or no signs of dehydration. LVN C said because resident was so contracted, the resident would have to call staff to help her get water. During an observation and interview on 08/06/2024 at 10:46 a.m., CNA E entered Resident #10's bedroom and said she assisted the other CNA in the hall to take Resident #10 to get a shower. CNA E said Resident #10 was assisted back to her room about 20 minutes ago and was transferred to her bed. CNA E said they must have forgotten to clip Resident #10's call pad within resident's reach. CNA E said resident was able to use the call pad to call for assistance when needed. During an interview on 08/08/2024 at 2:44 p.m., the DON said the purpose of the call button was for patients to call for staff assistance. The DON said she was familiar with Resident #10. The DON said Resident #10 was able to use the call light to call for assistance. The DON said the call light must be in reach of the resident. The DON said nurses and CNAs are responsible to ensure that the call button was in reach of the residents. The DON said the risk of the call button being out of reach of Resident #10 was that she would be unable to call for help or assistance including getting assistance with getting water. Surveyor requested a copy of the call light policy. Review of facility provided Resident Rights policy dated 11/28/2016, reads in part, The resident has a right to be treated with respect and dignity, including: the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. On 08/08/2024 at 2:44 p.m., the Surveyor requested copy of call light policy. The policy was not provided prior to exit.

Based on observations, interviews, and record reviews, the facility failed to ensure that the resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 (Resident #11) of 3 residents reviewed for resident rights. -The facility failed to ensure the urinary collection bag for Resident #11's catheter was covered with a privacy bag. This failure could place residents at risk for a loss of dignity, decreased self-worth and decreased self-esteem. Findings included: Record review of Resident #11's Admission Record dated 08/07/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #11's diagnoses included neuromuscular dysfunction of bladder (unable to control bladder due to nerve damage), and history of urinary tract infections (an infection in any part of the urinary system). Record review of Resident #11's MDS dated [DATE], reflected a BIMS score of 15, which indicated the person is intact cognitively. Resident #11 had impairment to one side of upper extremity, and to both sides of lower extremities. Resident #11 had an indwelling catheter. Record review of Resident #11's Order Summary Report dated 08/07/2024, reflected an order started on 09/17/2021 to Ensure foley bag is in privacy bag while in bed or wheelchair every shift. Record review of Resident #11's Care Plan dated 08/07/2024, read in part Resident #11 has Suprapubic Catheter (surgically created connection between the urinary bladder and the skin used to drain urine from bladder) related to neuromuscular dysfunction of bladder. Part of the interventions included Position catheter bag and tubing below the level of the bladder and in a privacy bag. In an observation on 08/06/2024 at 10:55 a.m., Resident #11 was lying in bed with the bedroom door open and with the catheter collection bag attached to the frame of the bed and outside of a privacy bag viewable from the hall. Resident #11 was asleep at the time. During an observation and interview on 08/06/2024 at 11:01 a.m., LVN E entered Resident #11's bedroom and said the catheter collection bag should have been inside a privacy bag. LVN E said she did not know why the collection bag was not in a privacy bag. LVN E said Resident #11 had not gotten up from bed that day and required assistance for all transfers. LVN E said nurses and CNAs were responsible to ensure the collection bag was inside the privacy bag. In an observation and interview on 08/07/2024 at 9:09 a.m., Resident #11 was lying in bed awake eating his meal with the bedroom door open. The catheter collection bag was attached to the frame of the bed and outside of a privacy bag. Resident #11 said he had not gotten up from bed today. Resident #11 said he did not know why the collection bag was outside of the privacy bag. Resident #11 said he did not like for the collection bag to be visible for anyone passing but that staff take out the collection bag and just leave it out. During an interview on 08/08/2024 at 2:44 p.m., the DON said the purpose of using a privacy bag for the catheter collection bag was to provide privacy. The DON said it was the responsibility of the nurse and CNAs in the hall to ensure that the collection bag is attached to the frame and inside a privacy bag. The DON said the risk to the resident was resident privacy could be violated. Review of facility provided Catheter Care policy dated 02/2007, reads in part, Review the resident's plan of care daily for changes providing as much privacy as possible . Review of facility provided Resident Rights policy dated 11/28/2016, reads in part, The resident has a right to be treated with respect and dignity, including: the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Based on observation, interview, and record review, the facility failed to ensure residents who are incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #11) of 3 residents reviewed for catheter care. -The facility failed to ensure Residents #11's catheter leg strap was in place to secure the catheter. This failure could place residents with foley catheters at risk of catheter pulling causing pain. Findings included: Record review of Resident #11's Admission Record dated 08/07/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #11's diagnoses included neuromuscular dysfunction of bladder (unable to control bladder due to nerve damage), and history of urinary tract infections (an infection in any part of the urinary system). Record review of Resident #11's MDS dated [DATE], reflected a BIMS score of 15, which indicated the person is intact cognitively. Resident #11 had impairment to one side of upper extremity, and to both sides of lower extremities. Resident #11 required total assistance with toileting hygiene, and substantial/maximal assistance with bathing, dressing, and transfers. Resident #11 had an indwelling catheter. Record review of Resident #11's Order Summary Report dated 08/07/2024, reflected an order started on 09/17/2021 to Ensure catheter strap in place and holding every shift change as needed. Record review of Resident #11's Care Plan dated 08/07/2024, reads in part Resident #11 has Suprapubic Catheter related to neuromuscular dysfunction of bladder. Part of the interventions included Ensure tubing is anchored to the resident's leg or linens so that tubing is not pulling on the urethra. During an observation and interview on 08/07/2024 at 9:09 a.m., Resident #11 was lying in bed. Surveyor visited resident with LVN E. LVN E asked Resident #11 if she could see the catheter strap and resident agreed. LVN E observed there was no catheter strap in place anchored to the resident's leg or linen. LVN E said it should have been a piece of tape holding the catheter tubing. LVN E said there was no sign or any tape or any other securement in place. LVN E said the risk to Resident #11 was the catheter could be pulled out causing pain and discomfort. Resident #11 said he had not had the catheter pulled out while at the facility. LVN E said she was the nurse for the hall since 6:00 a.m. and did not know how long Resident #11 did not have a catheter strap on. LVN E said she checks for the securing/placement of the catheter strap every shift. During an interview on 08/08/2024 at 2:44 p.m., the DON said the purpose of the catheter strap was to hold the tubing in place. The DON said the placement of the strap was monitored by nursing per shift. The DON said Resident #11 had not had the catheter pulled out while at the facility. The DON said Resident #11 had personal history of UTIs but had not had one at the facility. The DON said the risk of not having the catheter strap in place was the catheter being pulled out which could cause pain and trauma. Review of facility provided Catheter Care policy dated 02/2007, reads in part, Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks .minimize friction or movement at insertion site.

Based on interview and record review the facility failed ensure alleged violations involving abuse, including sexual abuse/exploitation are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #2) of 4 residents reviewed for reporting. The facility failed to report Resident #2's sexual abuse/exploitation in which Resident #2 claimed CNA H had touched in her private parts and when wiping would stick his fingers inside her when he showered her to the Administrator, to other officials, and to State Survey Agency. An IJ Immediate Jeopardy (IJ) was identified on 02/16/24. The IJ template was provided to the facility on [DATE] at 3:01 PM. While the IJ was removed on 02/17/24, the facility remained out of compliance at a at a severity level of potential for more than minimal harm and a scope of pattern as the facility was continuing to monitor it's plan for effectiveness. This failure could place all residents at risk for sexual abuse/exploitation by not immediately reporting allegations of sexual abuse/exploitation to the proper authorities at the facility, other officials, and state survey agency. Findings Include: Record review of Resident #2's face sheet dated 02/13/24, revealed admission on 12/18/20 to the facility. Record review of Resident #2's most recent facility history and physical in the system dated 12/21/20, revealed a [AGE] year-old female (present age [AGE] year-old) diagnosed with Osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes), Vascular Dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage, and cachexia (a complicated metabolic syndrome related to underlying illness and characterized by muscle mass loss with or without fat mass loss). Record review of Resident #2's quarterly MDS dated [DATE], revealed a moderate impaired cognition BIMS (score is used regularly to measure and track a resident's cognitive decline or improvements) score of 11 to be able to make daily decision and recall information. Resident #2 needed partial/moderate (half the help) assistance from nursing staff to help in showering/bathing. Resident #2 was diagnosed with Non-Alzheimer's Dementia, muscle wasting, lack of coordination, and muscle weakness (no muscle strength). Record review of Resident #2's care plan dated 12/19/20, revealed for bathing she required two staff for assistances. Care plan dated 12/19/20 revealed impaired cognitive function or impaired thought processes due to Dementia. Engage the resident in simple, structed activities that avoid overly demanding tasks. Monitor/document/report to medical doctor any changes in cognitive function, specially changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding other, level of consciousness, mental status. Record review of Resident #2's Kardex (documentation on the facility system that CNAs use to view resident care) dated 02/17/24, revealed bathing: requires staff x2 for assistance. Record review of Resident #2's shower report dated 02/02/24 at 8:16 PM and 02/09/24 at 5:57 PM, revealed CNA H had showered/bathed Resident #2. Record review of CNA H's time sheet dated 02/02/24 and 02/09/24, revealed he had been working on Resident #2's shower days on Friday 02/02/24 and 02/09/24. Resident #2 showers on Mondays, Wednesdays and Fridays of every week. Record review of Resident #2's Weekly Assessments, Event Note Assessments, all other Assessments dated 02/12/24, revealed, from 02/02/24 to 02/13/24 did not indicate any assessments were conducted for the sexual abuse/exploitation allegation of Resident #2. Record review of Resident #2's Progress Notes dated 02/12/24 revealed, from 02/02/24 to 02/13/24, did not indicate any assessments were conducted or any information regarding the sexual abuse/exploitation allegation of Resident #2. Record review and observation of text message provided to surveyor between LVN F, LVN E, and DON 02/02/24 at 5:17 PM read as follows: LVN F when you get a chance can you go talk to Resident #2, she told the Business Office Assistant that when CNA H or CNA O bath her they do something to her. At 5:25 PM - LVN F stated, Yes I will. At 5:28 PM - DON stated, thank you, let me know what she says. At 6:08 PM - LVN F stated, Resident #2 says she feels CNA H touches her inappropriately when he's bathing her. At 6:13 PM - DON stated, OMG (oh my god). LVN F stated, Shouldn't the Social Worker and Administrator have interviewed Resident #2. I feel like that's serious allegations. LVN E stated, Resident #2 says that when CNA H's washing her he washes her Parts and she feels him put his fingers inside of her. DON - stated she would talk to her on Monday (unknown which Monday). LVN F stated, No one came to help out. Nothing else follows in the text message in regard to the sexual abuse/exploitation outcry from Resident #2. During an interview on 02/12/24 at 4:42 PM, with LVN F, he stated that he had received a text message on 0202/24 from the DON revealing that Resident #2 was stating CNA H was touching her in her private parts during shower/bath time. LVN F stated he and LVN E went to go speak with Resident #2 on 02/02/24 after he received the text message from the DON; in which she told them that CNA H was touching her and would stick his fingers inside of her when he showered her and did not want CNA H to shower her anymore. LVN F stated he thought it was a serious allegation and thought the Administrator and Social Worker would be the ones to go interview Resident #2 regarding her allegation. During an interview on 02/12/24 at 5:12 PM with LVN E, she stated the DON had sent LVN F a text message wanting for LVN F to go speak to Resident #2 about her allegation. LVN E stated that she went with LVN F to go talk to Resident #2 in which she stated that CNA H had touched her in her private parts. LVN E stated the DON and Administrator should have been the ones to go and interview Resident #2. LVN E stated Resident #2 claimed that CNA H would penetrate her through the shower chair and would go underneath the bottom of the shower chair. During an interview on 02/13/24 at 1:00 PM with Resident #2, she stated she had reported to LVN F that Resident #2 had been touching her down there when CNA H showers her. Resident #2 stated CNA H will put on his music and dance while he showers her. Resident #2 stated she did not have strength and was weak to fight back against CNA H. Resident #2 stated this happened everytime CNA H would shower her. Resident #2 stated she did not want CNA H around her and did not feel safe around him. Resident #2 stated she had not reported at first due to feeling embarrassed. During an interview on 02/13/24 at 1:35 PM with the DON, she stated that Resident #2 had made an outcry of sexual abuse/exploitation to the Business Office Assistant on 02/02/24. The DON stated the Business Office Assistant was told by Resident #2 that CNA H had touched Resident #2 in her private area. The DON stated she had instructed LVN F to go and speak with Resident #2 regarding the sexual abuse/exploitation outcry and report back to her what she had said. The DON stated she was still working on the investigation. The DON stated she had not done any assessments on Resident #2. The DON stated LVN E had done a body assessment for Resident #2, but it was not documented. The DON stated if it was not documented it did not happen. The DON stated she could not recall the exact date of Resident #2's sexual abuse/exploitation outcry. The DON stated she had not imputed anything into the computer. The DON stated there was no reason for the delay for not documenting and doing an assessment on Resident #2. The DON stated she would consider an outcry of sexual abuse/exploitation to be very important. The DON stated CNA H was not suspended and was still working at the facility and would not be able to answer why CNA H was not suspended. The DON stated CNA H was still working after the incident and there still existed a risk to the resident(s) of being sexually abuse/exploited. The DON stated it had not been reported to state survey agency and had no reason for the delay to notify state survey agency. The DON stated the Administrator was to report abuse and neglect allegations/incidents. The DON stated she had not reported it to the Administrator and said she had no explanation why she did not report it to her. During an interview on 02/13/24 at 2:55 PM with the Administrator, she stated she was unaware of the alleged allegation from Resident #2 of sexual abuse/exploitation. The Administrator stated she was just notified right now of the sexual abuse/exploitation outcry for Resident #2 from LVN F. The Administrator stated she was told by LVN F that Resident #2 had alleged CNA H had touched her inappropriately. The Administrator stated LVN F told the DON about what Resident #2 had alleged. The Administrator stated she was not told by the DON what Resident #2 had alleged. The Administrator stated once an outcry of an allegation has been made, it needed to be reported to the Abuse Coordinator which was her. The Administrator stated she would take measures to talk to the resident and see what had happened as well as suspend the staff to ensure the safety of the Resident #2 until the conclusion of the investigation. The Administrator stated there could be a risk if the outcome was proven correct in that CNA H did do the sexual abuse/exploitation. The Administrator stated she had sent CNA H home immediately as soon as she found out. The Administrator stated she still needed to go speak to Resident #2. The Administrator stated she did not know if a body assessment was conducted for Resident #2. The Administrator stated she did not report it to state survey agency as she was not notified of the sexual abuse/exploitation allegation. The Administrator stated facility staff were trained on abuse, neglect, and exploitation and facility staff did not follow the facility abuse policy protocol for reporting. The Administrator stated it would have been protocol for the nurses to do a body assessment. During an interview on 02/13/24 at 4:35 PM with the Social Worker, she stated she was just notified of the alleged allegation made of sexual abuse/exploitation from Resident #2 and was conducting interviews with the facility residents. The Social Worker stated Resident #2 had told her that she had reported CNA H. The Social Worker stated Resident #2 told her that CNA H touches her in her private parts and when he wipes her that he sticks his fingers in her. The Social Worker stated Resident #2 commented that CNA H puts on the music and begins to dance to it while he was showering her. The Social Worker stated Resident #2 had not reported it when it was happening because she felt embarrassed to report it and ashamed to tell her (family member). The Social Worker stated Resident #2 did not feel safe when CNA H was working at the facility. During an interview on 02/16/24 at 2:08 PM with the Administrator, she stated that law enforcement was not notified on 02/02/24. The Administrator stated during the investigation a head-to-toe assessment of Resident #2 was done by LVN F and LVN E indicating no harm to Resident #2. The Administrator stated the facility only contacts the police if there was harm. The Administrator stated both LVN F and LVN E did the body assessment but was only verbally communicated but there was not documentation of the incident or assessment. During an interview on 02/16/24 at 2:26 PM with LVN F, he stated he was never told to do a body assessment on Resident #2. LVN F stated there was no body assessment done on 02/02/24. LVN F stated he would have to have had a physician order or a directive from his DON to conduct the body assessment which there were none of. LVN F stated he was not trained or certified on assessing residents who claim sexual abuse/exploitation. LVN F stated he did not know what to look for. LVN F stated if he was looking for anything it would be bruises or marks on Resident #2. LVN F stated he recommended for Resident #2 to have been sent out to the hospital to have a rape kit done. LVN F stated on 02/13/24 he was told to go assess Resident #2. During an interview on 02/16/24 at 2:39 PM with LVN E, she stated she was never told to do a head-to-toe body assessment on Resident #2 on 02/02/24. LVN E stated she quickly checked Resident #2's thigh and opened up her brief to see if there was any bruises or marks but did not know what to look for as she was not trained or certified to conduct a sexual assessment on a resident. LVN E stated when a resident claims sexual abuse/exploitation that they were sent out to the hospital to go get checked out. LVN E stated on 02/13/24, she was directed to go assess Resident #2. During an interview on 02/17/24 at 5:02 PM with the Regional Nurse, she stated the facility nurses were not trained or certified to do sexual assessments but could assess the resident externally to see if there was any bruises or markings. Record review of the facility's Abuse/Neglect policy and procedure manual dated 03/29/18 revealed, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. It was each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Sexual Abuse: Non-consensual sexual contact of any type with a resident. Reporting - Any person having reasonable cause to believe an elderly or incapacitated adult was suffering from abuse, neglect, or exploitation must report this to the DON, Administrator, state and or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect, or financial exploitation of the elderly and incapacitated persons. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriate of resident properly or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet criteria of Provider Letter 19-17 dated 07/10/19. Record review of the facility's Documentation policy and procedure manual dated 2003 revealed, Documentation was the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has a legal requirement regarding accuracy and completeness, legibility, and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessments, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets weekly, daily, monthly, discharge). Goal- The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. The facility will ensure that information was comprehensive and timely and properly signed. Document completed assessments in a timely manner and per policy. Complete documentation in narrative nursing notes as needed in a timely manner. Daily documentation x72 hours will be required for each shift for new admissions, during and following an acute episode, following an incident, and during physiologic, mental, or emotional changes or instability. Record review of the facility Event Reporting: Completion Of (Regional Nurse stated this was the facility's accident policy) policy and procedure not dated revealed, Investigation: The investigation should be completed by the DON/Administrator or designee. The investigation report documents a though investigation of the events of the reported Event including person, equipment, and materials that were involved. The investigation report must include what actions were taken to prevent subsequent Events and signatures of the individuals as indicated on the form. The facility will complete an Event report on variances that occur with the facility. Variances include falls, skin tears, bruises, abrasions, lacerations, fractures, choking, burns, elopement, or behavior that affects others. Record review of the facility Bath, Tub/Shower policy and procedures dated 2003, revealed, The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level. The resident will experience improved comfort and cleanliness by bathing. Become familiar with type and pattern of bathing, assistance or aids needed, skin condition, presence of dress or casts. Remain with the resident if he was weak or assistance was needed in washing. The Administrator and DON were informed on 02/16/24 at 3:01 PM, that an Immediate Jeopardy (IJ) had been identified and a copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested. 02/16/24 at 5:19 PM - Area Director of operations submitted 1st Plan of Removal. 02/16/24 at 6:27 PM - Facility was notified of the 1st denied Plan of Removal. 02/16/24 at 7:51 PM - Administrator submitted 2nd Plan of Removal. 02/17/24 at 11:12 AM - Facility notified of 2nd denied Plan of Removal. 02/17/24 at 11:50 AM - Administrator was notified of approved Plan of Removal. The Plan of Removal revealed the facility took the following actions: Interventions: One on One in-service on Abuse Reporting with the Administrator, DON, and Social Worker by Area Director of Operation on 2/13/2024 at 4:30 pm Staff working with Alleged perpetrators have been interviewed by ADO. The resident is doing ok; no distress was noted, and the resident was able to voice concerns. The alleged perpetrator was suspended on 2/13/2024 at 4:30 pm, pending the outcome of the investigation. Investigation completed on 2/14/2024. Resident safety surveys were initiated by the social worker on 2/13/2024, and no abuse incidents have been reported. Completion date of 2/13/2024 DON was suspended on 2/16/24 at 4:30 pm, pending the outcome of the investigation. The following in-services were initiated on 2/13/2024 by Administrator/ADO: Any staff member not present or in-service on 2/13/2024 will not be allowed to assume their duties until in-service. o All Staff Abuse/Neglect Abuse/Neglect Reporting Who to Report Abuse/Neglect to All in-serviced staff will need to be able to articulate back on reporting any abuse allegation and to whom to report. Completion date 2/17/2024 o The administrator/designee will assess and monitor understanding by quizzing and providing examples on in-services. New staff will be in service during orientation. Any employees who are allegedly involved in any abuse will be suspended pending investigation. The medical director was notified of the immediate jeopardy situation on 2/16/2024 at 4:40. Monitoring The administrator will report any abuse allegations, investigate, and submit findings to the Area Director and Risk Management for review. The administrator will submit documentation of the investigation with Resident and Staff interviews, as well as weekly follow-up interviews with staff and residents x 4 weeks to ensure resident safety/satisfaction with the outcome of the investigation. The Area Director will monitor abuse allegations reported and check the real-time system, which monitors keywords like abuse x 4 weeks' documentation and PCC for any incidents and accidents. The QA committee will review findings of abuse allegations and investigations monthly and make changes to the system as needed. On 02/17/24 at 11:55 AM Verification phase began with the facility approved Plan of Removal. During an interview on 02/17/24 at 11:57 AM with the Administrator and Area Director of Operations, the Area director of Operations stated on 02/13/24 at 4:30 PM she had already in-serviced the Administrator, DON, and Social Worker regarding Abuse Reporting. The Administrator stated on 02/13/24 at 4:30 PM CNA H was suspended pending the outcome of the investigation for Resident #2. The Area Director of Operations stated on 02/16/24 at 4:30 PM the DON was suspended pending the outcome of the investigation. The Area Director of Operations stated the facility had completed the investigation on 02/14/24, for Resident #2 and was found to be unconfirmed. The Administrator stated on 02/13/24 a Safety Survey of the residents was conducted by the Social Worker and found no abuse incidents had been reported by the residents. The Administrator stated the facility was moving forward with termination of CNA H with unrelated issues to the alleged allegation. The Administrator stated Resident #2 stated she was doing fine, able to voice concerns, and no distress was noted. The Administrator and Area Director of Operations stated on 02/13/24 an in-service was initiated by both Administrator and Area Director of Operations for Abuse/Neglect, Abuse/Neglect Reporting, and Who to report Abuse/Neglect too. The Administrator stated facility staff not present, during the in-service will not be allowed to resume their duties until in-serviced. The Administrator stated on 02/17/24 all in-services provided to facility staff had to be communicate back to the presenter acknowledging they understood what was being in-serviced on. The Administrator stated quizzes were given and examples had to be provided by the in-service-e confirming understanding of the material. The Administrator stated new employees would be in-serviced on during orientation. The Administrator stated all alleged employees involved in an allegation will be suspended pending the outcome of the investigation. The Area Director of Operation stated on 02/16/24 at 4:40 PM the Medical Director was notified of the Immediate Jeopardy, commenting that the facility will have to get better. The Area Director of Operation stated the Administrator was to report any and all allegations of abuse and submit all documentation for investigations conducted which would be reviewed by Area Director of Operations and Risk Management. The Area Director of Operations stated the Administrator was also to submit interviews with staff and residents related to investigations four times a week to ensure safety/satisfaction outcomes. The Area Director of Operations stated the facility system will be checked for key words like abuse four times a week for incidents or accidents that might have happened or have been documented. The Administrator stated an off-cycle Quality Assurance meeting was held on 02/16/24 at 5:00 PM, regarding the Immediate Jeopardy and follow ups will be held monthly to see if adjustments are needed to abuse allegations and investigations. During an interview on 02/17/24 at 12:42 PM with LVN P, he stated, he had received an in-service on abuse. LVN P stated that any kind abuse had to be reported to the Administrator immediately. LVN P stated during the in-service it was talked about the 5 different types of abuses such as emotional, verbal, physical, sexual, and financial abuse to include injuries of unknown origin. LVN P stated that the in-servicer did test his knowledge on the material by asking him questions and giving him a quiz on it. During an interview on 02/17/24 at 12:48 PM with LVN Q, he stated, he received an in-service on abuse and neglect. LVN Q stated as soon as an alleged allegation was made or suspect, it must be reported immediately to the Administrator. LVN Q stated he was asked questions about the in-service he had received and had to answer them. During an interview on 02/17/24 at 12:42 PM with LVN I, she stated, she had received several in-services such as abuse. LVN I stated she was told of the different types of abuses and if she saw or suspected abuse happening who to report it to. LVN I stated she had to report abuse to the Administrator who was the Abuse Coordinator. LVN I stated she was questioned on the in-service like it was a test. During an interview on 02/17/24 at 1:15 PM with MA R, she stated, she was in-serviced on abuse and neglect. MA R stated any suspected or seen abuse had to be report to the Abuse Coordinator which was the Administrator. MA R stated she was questioned on what was in-serviced. During an interview on 02/17/24 at 1:23 PM with ADON G, she stated, she had received an in-service regarding abuse and neglect. ADON G stated they told her what constitutes abuse and neglect and who to report it to. ADON G stated abuse was reported to the Administrator immediately. ADON G stated she was questioned over the in-service(s) of abuse to check her knowledge. During an interview on 02/17/24 at 1:31 PM with CNA T, she stated, an in-service of abuse was given to her. CNA T stated it entailed what abuse was and the different types. CNA T stated she was questioned over the material being presented. CNA T stated any kind of abuse had to be reported immediately to the Administrator. During an interview on 02/17/24 at 1:43 PM with CNA U, she stated, she was in-serviced on abuse regarding the different types of abuse. CNA U stated staff were to report if someone talks bad or physically hits a resident. bad or physically hits them. CNA U stated it had to be reported to the Administrator. CNA U stated she had received a quiz on the in-service. During an interview on 02/17/24 at 1:52 PM with LVN V, she stated, she had received an in-service on abuse and neglect on 02/16/24. LVN V stated to report anything the facility staff felt was abuse and who to report it to. LVN V stated it was to be reported to the Abuse Coordinator which was the Administrator. LVN V stated she was asked questions about what they felt it was reportable and why. Record review of the facility Monitoring Tools dated 02/17/24, revealed, the following: In-Services - The Administrator will audit all new employee filles to ensure in-services are being completed. Ensure Quizzes are being completed - Administrator will gather quiz sheet 3 per day. Record review of the facility In-services dated 02/13/24, 02/14/24, 02/16/24 revealed, the following: Abuse Reporting/Investigation Abuse and Neglect After the Plan or Removal and Monitoring: The Administrator was informed the Immediate Jeopardy was removed on 02/17/24 at 3:35 PM. The facility remained out of compliance at a at a severity level of potential for more than minimal harm and a scope of pattern as the facility was continuing to monitor it's plan for effectiveness.

Based on interview, and record review the facility failed to ensure violations are thoroughly investigated with results of the investigations presented to the administrator and to other officials in accordance with state law including to state survey agency, within 5 working days of the incident and if the alleged violation is verified appropriate corrective action must be taken for 1 (Resident #1) of 4 residents reviewed for incidents. The facility failed did not thoroughly investigate Resident #2's sexual abuse/exploitation in which Resident #2 claimed CNA H had touched in her private parts and when wiping would stick his fingers inside her when he showered her to the Administrator, to other officials, and to State Survey Agency. An IJ Immediate Jeopardy (IJ) was identified on 02/16/24. The IJ template was provided to the facility on [DATE] at 3:01 PM. While the IJ was removed on 02/17/24, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern as the facility was continuing to monitor it's plan for effectiveness. These failures could place residents at risk for abuse, neglect, exploitation, and elopement and decreased quality of life. Findings include: Record review of Resident #2's face sheet dated 02/13/24, revealed, admission on 12/18/20 to the facility. Record review of Resident #2's most recent facility history and physical in the system dated 12/21/20, revealed, a [AGE] year-old female (present age [AGE] year-old) diagnosed with Osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes), Vascular Dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage, and cachexia (a complicated metabolic syndrome related to underlying illness and characterized by muscle mass loss with or without fat mass loss). Record review of Resident #2's quarterly MDS dated [DATE], revealed, a cognitively intact BIMS (score is used regularly to measure and track a resident's cognitive decline or improvements) score of 11 to be able to make daily decision and recall information. Resident #2 needed partial/moderate (half the help) assistance from nursing staff to help in showering/bathing. Resident #14 was diagnosed with Non-Alzheimer's Dementia, muscle wasting, lack of coordination, and muscle weakness (no muscle strength). Record review of Resident #2's care plan dated 12/19/20, revealed for bathing she required two staff for assistances. Care plan dated 12/19/20 revealed impaired cognitive function or impaired thought processes due to Dementia. Engage the resident in simple, structed activities that avoid overly demanding tasks. Monitor/document/report to medical doctor any changes in cognitive function, specially changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding other, level of consciousness, mental status. Record review of Resident #2's Kardex (documentation on the facility system that CNAs use to view resident care) dated 02/17/24, revealed bathing: requires staff x2 for assistance. Record review of Resident #2's shower report dated 02/02/24 at 8:16 PM and 02/09/24 at 5:57 PM, revealed CNA H had showered/bathed Resident #2. Record review of CNA H's time sheet dated 02/02/24 and 02/09/24, revealed he had been working on Resident #2's shower days on Friday 02/02/24 and 02/09/24. Resident #2 showers on Mondays, Wednesdays and Fridays of every week. Record review of Resident #2's Weekly Assessments, Event Note Assessments, all other Assessments dated 02/12/24, revealed, from 02/02/24 to 02/13/24 did not indicate any assessments were conducted for the sexual abuse/exploitation allegation of Resident #2. Record review of Resident #2's Progress Notes dated 02/12/24 revealed, from 02/02/24 to 02/13/24, did not indicate any assessments were conducted or any information regarding the sexual abuse/exploitation allegation of Resident #2. Record review and observation of text message provided to surveyor between LVN F, LVN E, and DON 02/02/24 at 5:17 PM read as follows: LVN F when you get a chance can you go talk to Resident #2, she told the Business Office Assistant that when CNA H or CNA O bath her they do something to her. At 5:25 PM - LVN F stated, Yes I will. At 5:28 PM - DON stated, thank you, let me know what she says. At 6:08 PM - LVN F stated, Resident #2 says she feels CNA H touches her inappropriately when he's bathing her. At 6:13 PM - DON stated, OMG (oh my god). LVN F stated, Shouldn't the Social Worker and Administrator have interviewed Resident #2. I feel like that's serious allegations. LVN E stated, Resident #2 says that when CNA H's washing her he washes her Parts and she feels him put his fingers inside of her. DON - stated she would talk to her on Monday (unknown which Monday). LVN F stated, No one came to help out. Nothing else follows in the text message in regard to the sexual abuse/exploitation outcry from Resident #2. During an interview on 02/12/24 at 4:42 PM, with LVN F, he stated, that he had received a message form the DON revealing that Resident #2 was stating CNA H was touching her in her private parts during shower/bathe time. LVN F stated he and LVN E went ot go speak with Resident #2 in which she told them that CNA H was touching her and would stick his fingers inside of her when he showered her and did not want CNA H to shower her anymore. LVN F stated he though it was a serious allegation and though the Administrator and Social Worker would be the ones to go interview Resident #2 regarding her allegation. During an interview on 02/12/24 at 5:12 PM, with LVN E, she stated, the DON had sent LVN F a text message wanting for LVN F to go speak to Resident #2 about her allegation. LVN E stated that she went with LVN F to go talk to Resident #2 in which she stated that CNA H had touched her in her private parts. LVN E stated the DON and Administrator should have been the ones to go and interview Resident #2. LVN E stated Resident #2 claimed that CNA H would penetrate her through the shower chair and would go underneath the bottom of the shower chair. During an interview on 02/13/24 at 1:00 PM, with Resident #2, she stated, she had reported to LVN F that Resident #2 had been touching her down there when CNA H showers her. Resident #2 stated CNA H will put on his music and dance while he showers her. Resident #2 stated she did not have strength and was weak to fight back against CNA H. Resident #2 stated she did not want CNA H around her and did not feel safe around him. Resident #2 stated she had not reported it due to feeling embarrassed. During an interview on 02/13/24 at 1:35 PM, with the DON, she stated that Resident #2 had made an outcry of sexual abuse/exploitation to the Business Office Assistant. The DON stated the Business Office Assistant was told by Resident #2 that CNA H had touched Resident #2 in her private area. The DON stated she had instructed LVN F to go and speak with Resident #2 regarding the sexual abuse/exploitation outcry and report back to her what she had said. The DON stated she was still working on the investigation. The DON stated she had not done any assessments on Resident #2. The DON stated LVN E had done a body assessment for Resident #2 but was not documented. The DON stated if it was not documented it did not happen. The DON stated she could not recall the exact date of Resident #2's sexual abuse/exploitation outcry. The DON stated she had not imputed anything into the computer. The DON stated there was no reason for the delay for not documenting and doing an assessment on Resident #2. The DON stated she would consider an outcry of sexual abuse/exploitation to be very important. The DON stated CNA H was not suspended and was still working at the facility and would not be able to answer why CNA H was not suspended. The DON stated CNA H was still working after the incident and there still existed a risk to the resident(s) of being sexually abuse/exploited. The DON stated it had not been reported to state survey agency and had no reason for the delay to notify state survey agency. The DON stated the Administrator was to report abuse and neglect allegations/incidents. During an interview on 02/13/24 at 2:55 PM, with the Administrator, she stated she was unaware of the alleged allegation from Resident #2 of sexual abuse/exploitation. The Administrator stated she was just notified right now of the sexual abuse/exploitation outcry for Resident #2 from LVN F. The Administrator stated she was told by LVN F that Resident #2 had alleged CNA H had touched her incorrectly. The Administrator stated LVN F told the DON about what Resident #2 had alleged. The Administrator stated she was not told by the DON what Resident #2 had alleged. The Administrator stated once an outcry of an allegation has been made it needed to be reported to the Abuse Coordinator which was her. The Administrator started she would take measures to talk to the resident and see what had happened as well as suspend the staff to ensure the safety of the Resident #2 until the conclusion of the investigation. The Administrator stated there could be a risk if the outcome was proven correct in that CNA H did do the sexual abuse/exploitation. The Administrator stated she had sent CNA H immediately as soon as she found out. The Administrator stated she still needed to go speak to Resident #2. The Administrator stated she did not know if a body assessment was conducted for Resident #2. The Administrator stated she did not report it to state survey agency as she not notified of the sexual abuse/exploitation allegation. The Administrator stated facility staff are trained on abuse, neglect, and exploitation and facility staff did not follow the facility abuse policy protocol for reporting. The Administrator stated it would have been protocol for the nurses to do a body assessment. During an interview on 02/13/24 at 4:35 PM, with the Social Worker, she stated she was just notified of the alleged allegation made of sexual abuse/exploitation from Resident #2 and was conducting interviews with facility residents. The Social Worker stated Resident #2 had told her that she had reported CNA H. Social Worker stated Resident #2 told her that CNA H touches her in her private parts and when he wipes her that he sticks his fingers in her. The Social Worker stated Resident #2 commented that CNA H puts on the music and begins to dance to it while he is showering her. The Social Worker stated Resident #2 had not reported it early because she felt embarrassed to report it and ashamed to tell her family member. The Social Worker stated Resident #2 did not feel safe when CNA H was working at the facility. During an interview on 02/16/24 at 2:08 PM with the Administrator, she stated that law enforcement was not notified on 02/02/24. The Administrator stated during the investigation a head-to-toe assessment of Resident #2 was done by LVN F and LVN E indicating no harm to Resident #2. The Administrator stated the facility only contacts the police if there was harm. The Administrator stated both LVN F and LVN E did the body assessment but was only verbally communicated but there was not documentation of the incident or assessment. During an interview on 02/16/24 at 2:26 PM with LVN F, he stated he was never told to do a body assessment on Resident #2. LVN F stated there was no body assessment done on 02/02/24. LVN F stated he would have to have had a physician order or a directive from his DON to conduct the body assessment which there were none of. LVN F stated he was not trained or certified on assessing residents who claim sexual abuse/exploitation. LVN F stated he did not know what to look for. LVN F stated if he was looking for anything it would be bruises or marks on Resident #2. LVN F stated he recommended for Resident #2 to have been sent out to the hospital to have a rape kit done. LVN F stated on 02/13/24 I was told to go assess Resident #2. During an interview on 02/16/24 at 2:39 PM with LVN E, she stated she was never told to do a head-to-toe body assessment on Resident #2 on 02/02/24. LVN E stated she quickly checked Resident #2's thigh and open up her brief to see if there was any bruises or marks but did not know what to look for as see was not trained or certified to conduct a sexual assessment on a resident. LVN E stated when a resident claims sexual abuse/exploitation that they are sent out to the hospital to go get checked out. LVN F stated on 02/13/24, I was directed to go assess Resident #2. During an interview on 02/17/24 at 5:02 PM with Regional Nurse, she stated the facility nurses were not trained or certified to do sexual assessments but could assess the resident eternally to see if there was any bruises or markings. Record review of the facility Abuse/Neglect policy and procedure manual dated 03/29/18, revealed, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. It was each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Sexual Abuse: Non-consensual sexual contact of any type with a resident. Reporting - Any person having reasonable cause to believe an elderly or incapacitated adult was suffering from abuse, neglect, or exploitation must report this to the DON, Administrator, state and or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect, or financial exploitation of the elderly and incapacitated persons. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriate of resident properly or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet criteria of Provider Letter 19-17 dated 07/10/19. Investigation - Comprehensive investigations will be the responsibility of the administrator and or the Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated. Record review of the facility Documentation policy and procedure manual dated 2003, revealed, Documentation was the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has a legal requirement regarding accuracy and completeness, legibility, and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessments, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets weekly, daily, monthly, discharge). Goal- The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. The facility will ensure that information was comprehensive and timely and properly signed. Document completed assessments in a timely manner and per policy. Complete documentation in narrative nursing notes as needed in a timely manner. Daily documentation x72 hours will be required for each shift for new admissions, during and following an acute episode, following an incident, and during physiologic, mental, or emotional changes or instability. Record review of the facility Event Reporting: Completion Of (Regional Nurse stated this was the facility's accident policy) policy and procedure not dated revealed, Investigation: The investigation should be completed by the DON/Administrator or designee. The investigation report documents a though investigation of the events of the reported Event including person, equipment, and materials that were involved. The investigation report must include what actions were taken to prevent subsequent Events and signatures of the individuals as indicated on the form. The facility will complete an Event report on variances that occur with the facility. Variances include falls, skin tears, bruises, abrasions, lacerations, fractures, choking, burns, elopement, or behavior that affects others. Record review of the facility Bath, Tub/Shower policy and procedures dated 2003, revealed, The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level. The resident will experience improved comfort and cleanliness by bathing. Become familiar with type and pattern of bathing, assistance or aids needed, skin condition, presence of dress or casts. Remain with the resident if he was weak or assistance was needed in washing. The Administrator and DON were informed on 02/16/24 at 3:01 PM, that an Immediate Jeopardy (IJ) had been identified and a copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested. 02/16/24 at 5:19 PM - Area Director of operations submitted 1st Plan of Removal. 02/16/24 at 6:27 PM - Facility was notified of the 1st denied Plan of Removal. 02/16/24 at 7:51 PM - Administrator submitted 2nd Plan of Removal. 02/17/24 at 11:12 AM - Facility notified of 2nd denied Plan of Removal. 02/17/24 at 11:50 AM - Administrator was notified of approved Plan of Removal. The Plan of Removal revealed the facility took the following actions: Interventions: One on One in-service on conduct a thorough investigation when allegations are made and report to State Office to ensure supervision with the Administrator, DON and Social Worker by Area Director of Operation on 2/16/2024 at 4:30 pm Staff working with Alleged perpetrators have been interviewed by ADO. The resident #2 is doing ok; no distress was noted, and the resident was able to voice concerns. The alleged perpetrator was suspended on 2/13/2024 at 4:30 pm, pending the outcome of the investigation. Investigation completed on 2/14/2024. Resident safety surveys were initiated by the social worker on 2/13/2024, and no abuse incidents have been reported. Completion date of 2/13/2024. The following in-services were initiated on 2/13/2024 by Administrator/ADO: Any staff member not present or in-service on 2/13/2024 will not be allowed to assume their duties until in-service. o All Staff Abuse/Neglect Abuse/Neglect Reporting Who to Report Abuse/Neglect to All in-serviced staff will need to be able to articulate back on reporting any abuse allegation and to whom to report. Completion date 2/17/2024 o The administrator/designee will assess and monitor understanding by quizzing and providing examples on in-services. New staff will be in service during orientation. Any employees who are allegedly involved in any abuse will be suspended pending investigation. The medical director was notified of the immediate jeopardy situation on 2/16/2024 at 4:40. Monitoring The administrator will report any abuse allegations, investigate, and submit findings to the Area Director and Risk Management for review. The administrator will submit documentation of the investigation with Resident and Staff interviews, as well as weekly follow-up interviews with staff and residents x 4 weeks to ensure resident safety/satisfaction with the outcome of the investigation. The Area Director will monitor abuse allegations reported and check the real-time system which monitors keywords like abuse x 4 weeks documentation and PCC for any incident and accidents. The QA committee will review findings of any abuse allegations and investigations monthly and make changes as needed to the system. On 02/17/24 at 11:55 AM Verification phase began with the facility approved Plan of Removal. During an interview on 02/17/24 at 11:57 AM, with the Administrator and Area Director of Operations, the Administrator stated the present facility staff were in-serviced regarding, No Residents to be left unsurprised in the patio area. The Area Director of operations stated all facility staff not present were called and in-serviced regarding, No Resident to be left unsurprised in the patio area. The Administrator stated all facility staff were in-serviced by 02/16/24. The Area director of Operations stated on 02/13/24 at 4:30 PM she had already in-serviced the Administrator, DON, and Social Worker regarding Abuse Reporting. The Administrator stated on 02/13/24 at 4:30 PM CNA H was suspended pending the outcome of the investigation for Resident #2. The Area Director of Operations stated on 02/16/24 at 4:30 PM the DON was suspended pending the outcome of the investigation. The Area Director of Operations stated the facility had completed the investigation on 02/14/24, for Resident #2 and was found to be unconfirmed. The Administrator stated on 02/13/24 a Safety Survey of the residents was conducted by the Social Worker and found no abuse incidents had been reported by the residents. The Administrator stated the facility was moving forward with termination of CNA H with unrelated issues to the alleged allegation. The Administrator stated Resident #2 stated she was doing fine, able to voice concerns, and no distress was noted. The Administrator and Area Director of Operations stated on 02/13/24 an in-service was initiated by both Administrator and Area Director of Operations for Abuse/Neglect, Abuse/Neglect Reporting, and Who to report Abuse/Neglect too. The Administrator stated facility staff not present, during the in-service will not be allowed to resume their duties until in-serviced. The Administrator stated on 02/17/24 all in-services provided to facility staff had to be communicate back to the presenter acknowledging they understood what was being in-serviced on. The Administrator stated quizzes were given and examples had to be provided by the in-service-e confirming understanding of the material. The Administrator stated new employee would be in-serviced on during orientation. The Administrator stated all alleged employees involved in an allegation will be suspended pending the outcome of the investigation. The Area Director of Operation stated on 02/16/24 at 4:40 PM the Medical Director was notified of the Immediate Jeopardy, commenting that the facility will have to get better. The Area Director of Operation stated the Administrator was to report any and all allegations of abuse and submit all documentation for investigations conduct which would be reviewed by Area Director of Operations and Risk Management. The Area Director of Operations stated the Administrator was also to submit interviews with staff and residents related to investigations four times a week to ensure safety/satisfaction outcomes. The Area Director of Operations stated the facility system will be checked for key words like abuse four times a week for incidents or accidents that might have happened or been documented. The Administrator stated an off-cycle Quality Assurance meeting was held on 02/16/24 at 5:00 PM, regarding the Immediate Jeopardy and follow ups will be held monthly to see if adjustments were needed to abuse allegations and investigations. During an interview on 02/17/24 at 12:42 PM, with LVN P, he stated, he had received an in-service on abuse. LVN P stated that any kind of abuse had to be reported to the Administrator immediately. LVN P stated during the in-service it was talked about the 5 different types of abuses such as emotional, verbal, physical, sexual, and financial abuse to include injuries of unknown origin. LVN P stated that the in-servicer did test his knowledge on the material by asking him questions and giving him a quiz on it. During an interview on 02/17/24 at 12:48 PM, with LVN Q, he stated, he received an in-service on abuse and neglect. LVN Q stated as soon as an alleged allegation was made or suspected, must be reported immediately to the Administrator. LVN Q stated he was asked questions about the in-service he had received and had to answer them. During an interview on 02/17/24 at 12:42 PM, with LVN I, she stated, she had received several in-services such as abuse. LVN I stated she was told of the different types of abuses and if she saw or suspected abuse happening who to report it to. LVN I stated she had to report abuse to the Administrator who was the Abuse Coordinator. LVN I stated she was questioned on the in-service like it was a test. During an interview on 02/17/24 at 1:15 PM, with MA R, she stated, she was in-serviced on abuse and neglect. MA R stated any suspected or seen abuse had to be reported to the Abuse Coordinator which was the Administrator. MA R stated she was questioned on what was in-serviced. During an interview on 02/17/24 at 1:23 PM, with ADON G, she stated, she had received an in-service regarding abuse and neglect. ADON G stated they told her what constitutes abuse and neglect and who to report it to. ADON G stated abuse was reported to the Administrator immediately. ADON G stated she was questioned over the in-service(s) of abuse to check her knowledge. During an interview on 02/17/24 at 1:31 PM, with CNA T, she stated, an in-service of abuse was given to her. CNA T stated it entailed what abuse was like the five different types. CNA T stated she was questioned over the material being presented. CNA T stated any kind of abuse had to be reported immediately to the Administrator. During an interview on 02/17/24 at 1:43 PM, with CNA U, she stated, she was in-serviced on abuse regarding the different types of abuse. CNA U stated staff are to do report if someone talks bad or physically hits a resident. bad or physically hits them. CNA U stated it had to be reported to the Administrator. CNA U stated she had received a quiz on the in-service. During an interview on 02/17/24 at 1:52 PM, with LVN V, she stated, she had received an in-service on abuse and neglect on 02/16/24. LVN V stated to report anything the facility staff felt was abuse and who to report it too. LVN V stated it was to be reported to the Abuse Coordinator which was the Administrator. LVN V stated she was asked questions about they felt it was reportable and why. After the Plan or Removal and Monitoring: The Administrator was informed the Immediate Jeopardy was removed on 02/17/24 at 3:35 PM. The facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern as the facility was continuing to monitor it's plan for effectiveness.

Based on interviews and record review the facility failed to implement written policies that prohibit and prevent abuse for one (Resident #2) of four residents reviewed for abuse The facility failed to implement their abuse policy when they failed to report, investigate and protect residents from further potential abuse when Resident #2 made an allegation of sexual abuse An IJ Immediate Jeopardy (IJ) was identified on 02/16/24. The IJ template was provided to the facility on [DATE] at 3:01 PM. While the IJ was removed on 02/17/24, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern as the facility was continuing to monitor its plan for effectiveness. This failure could place all residents at risk for sexual abuse/exploitation and other abuses by not immediately following the facility policy and procedure manual of recognizing, reporting, investigating, allegations of sexual abuse/exploitation and other abuses. Findings Include: Record review of the facility Abuse/Neglect policy and procedure manual dated 03/29/18, revealed, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. It was each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Sexual Abuse: Non-consensual sexual contact of any type with a resident. Reporting - Any person having reasonable cause to believe an elderly or incapacitated adult was suffering from abuse, neglect, or exploitation must report this to the DON, Administrator, state and or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect, or financial exploitation of the elderly and incapacitated persons. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriate of resident properly or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet criteria of Provider Letter 19-17 dated 07/10/19. Investigation - Comprehensive investigations will be the responsibility of the administrator and or the Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated. Record review of Resident #2's face sheet dated 02/13/24, revealed admission on 12/18/20 to the facility. Record review of Resident #2's most recent facility history and physical in the system dated 12/21/20, revealed a [AGE] year-old female (present age [AGE] year-old) diagnosed with Osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes), Vascular Dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage, and cachexia (a complicated metabolic syndrome related to underlying illness and characterized by muscle mass loss with or without fat mass loss). Record review of Resident #2's quarterly MDS dated [DATE], revealed a moderate impaired cognition BIMS (score is used regularly to measure and track a resident's cognitive decline or improvements) score of 11 to be able to make daily decision and recall information. Resident #2 needed partial/moderate (half the help) assistance from nursing staff to help in showering/bathing. Resident #2 was diagnosed with Non-Alzheimer's Dementia, muscle wasting, lack of coordination, and muscle weakness (no muscle strength). Record review of Resident #2's care plan dated 12/19/20, revealed for bathing she required two staff for assistances. Care plan dated 12/19/20 revealed impaired cognitive function or impaired thought processes due to Dementia. Engage the resident in simple, structed activities that avoid overly demanding tasks. Monitor/document/report to medical doctor any changes in cognitive function, specially changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding other, level of consciousness, mental status. Record review of Resident #2's Kardex (documentation on the facility system that CNAs use to view resident care) dated 02/17/24, revealed bathing: requires staff x2 for assistance. Record review of Resident #2's shower report dated 02/02/24 at 8:16 PM and 02/09/24 at 5:57 PM, revealed CNA H had showered/bathed Resident #2. Record review of CNA H's time sheet dated 02/02/24 and 02/09/24, revealed he had been working on Resident #2's shower days on Friday 02/02/24 and 02/09/24. Resident #2 showers on Mondays, Wednesdays and Fridays of every week. Record review of Resident #2's Weekly Assessments, Event Note Assessments, all other Assessments dated 02/12/24, revealed, from 02/02/24 to 02/13/24 did not indicate any assessments were conducted for the sexual abuse/exploitation allegation of Resident #2. Record review of Resident #2's Progress Notes dated 02/12/24 revealed, from 02/02/24 to 02/13/24, did not indicate any assessments were conducted or any information regarding the sexual abuse/exploitation allegation of Resident #2. Record review and observation of text message provided to surveyor between LVN F, LVN E, and DON 02/02/24 at 5:17 PM read as follows: LVN F when you get a chance can you go talk to Resident #2, she told the Business Office Assistant that when CNA H or CNA O bath her they do something to her. At 5:25 PM - LVN F stated, Yes I will. At 5:28 PM - DON stated, thank you, let me know what she says. At 6:08 PM - LVN F stated, Resident #2 says she feels CNA H touches her inappropriately when he's bathing her. At 6:13 PM - DON stated, OMG (oh my god). LVN F stated, Shouldn't the Social Worker and Administrator have interviewed Resident #2. I feel like that's serious allegations. LVN E stated, Resident #2 says that when CNA H's washing her he washes her Parts and she feels him put his fingers inside of her. DON - stated she would talk to her on Monday (unknown which Monday). LVN F stated, No one came to help out. Nothing else follows in the text message in regard to the sexual abuse/exploitation outcry from Resident #2. During an interview on 02/12/24 at 4:42 PM, with LVN F, he stated that he had received a text message on 0202/24 from the DON revealing that Resident #2 was stating CNA H was touching her in her private parts during shower/bath time. LVN F stated he and LVN E went to go speak with Resident #2 on 02/02/24 after he received the text message from the DON; in which she told them that CNA H was touching her and would stick his fingers inside of her when he showered her and did not want CNA H to shower her anymore. LVN F stated he thought it was a serious allegation and thought the Administrator and Social Worker would be the ones to go interview Resident #2 regarding her allegation. During an interview on 02/12/24 at 5:12 PM with LVN E, she stated the DON had sent LVN F a text message wanting for LVN F to go speak to Resident #2 about her allegation. LVN E stated that she went with LVN F to go talk to Resident #2 in which she stated that CNA H had touched her in her private parts. LVN E stated the DON and Administrator should have been the ones to go and interview Resident #2. LVN E stated Resident #2 claimed that CNA H would penetrate her through the shower chair and would go underneath the bottom of the shower chair. During an interview on 02/13/24 at 1:00 PM with Resident #2, she stated she had reported to LVN F that Resident #2 had been touching her down there when CNA H showers her. Resident #2 stated CNA H will put on his music and dance while he showers her. Resident #2 stated she did not have strength and was weak to fight back against CNA H. Resident #2 stated this happened everytime CNA H would shower her. Resident #2 stated she did not want CNA H around her and did not feel safe around him. Resident #2 stated she had not reported at first due to feeling embarrassed. During an interview on 02/13/24 at 1:35 PM with the DON, she stated that Resident #2 had made an outcry of sexual abuse/exploitation to the Business Office Assistant on 02/02/24. The DON stated the Business Office Assistant was told by Resident #2 that CNA H had touched Resident #2 in her private area. The DON stated she had instructed LVN F to go and speak with Resident #2 regarding the sexual abuse/exploitation outcry and report back to her what she had said. The DON stated she was still working on the investigation. The DON stated she had not done any assessments on Resident #2. The DON stated LVN E had done a body assessment for Resident #2, but it was not documented. The DON stated if it was not documented it did not happen. The DON stated she could not recall the exact date of Resident #2's sexual abuse/exploitation outcry. The DON stated she had not imputed anything into the computer. The DON stated there was no reason for the delay for not documenting and doing an assessment on Resident #2. The DON stated she would consider an outcry of sexual abuse/exploitation to be very important. The DON stated CNA H was not suspended and was still working at the facility and would not be able to answer why CNA H was not suspended. The DON stated CNA H was still working after the incident and there still existed a risk to the resident(s) of being sexually abuse/exploited. The DON stated it had not been reported to state survey agency and had no reason for the delay to notify state survey agency. The DON stated the Administrator was to report abuse and neglect allegations/incidents. The DON stated she had not reported it to the Administrator and said she had no explanation why she did not report it to her. During an interview on 02/13/24 at 2:55 PM with the Administrator, she stated she was unaware of the alleged allegation from Resident #2 of sexual abuse/exploitation. The Administrator stated she was just notified right now of the sexual abuse/exploitation outcry for Resident #2 from LVN F. The Administrator stated she was told by LVN F that Resident #2 had alleged CNA H had touched her inappropriately. The Administrator stated LVN F told the DON about what Resident #2 had alleged. The Administrator stated she was not told by the DON what Resident #2 had alleged. The Administrator stated once an outcry of an allegation has been made, it needed to be reported to the Abuse Coordinator which was her. The Administrator stated she would take measures to talk to the resident and see what had happened as well as suspend the staff to ensure the safety of the Resident #2 until the conclusion of the investigation. The Administrator stated there could be a risk if the outcome was proven correct in that CNA H did do the sexual abuse/exploitation. The Administrator stated she had sent CNA H home immediately as soon as she found out. The Administrator stated she still needed to go speak to Resident #2. The Administrator stated she did not know if a body assessment was conducted for Resident #2. The Administrator stated she did not report it to state survey agency as she was not notified of the sexual abuse/exploitation allegation. The Administrator stated facility staff were trained on abuse, neglect, and exploitation and facility staff did not follow the facility abuse policy protocol for reporting. The Administrator stated it would have been protocol for the nurses to do a body assessment. During an interview on 02/13/24 at 4:35 PM with the Social Worker, she stated she was just notified of the alleged allegation made of sexual abuse/exploitation from Resident #2 and was conducting interviews with the facility residents. The Social Worker stated Resident #2 had told her that she had reported CNA H. The Social Worker stated Resident #2 told her that CNA H touches her in her private parts and when he wipes her that he sticks his fingers in her. The Social Worker stated Resident #2 commented that CNA H puts on the music and begins to dance to it while he was showering her. The Social Worker stated Resident #2 had not reported it when it was happening because she felt embarrassed to report it and ashamed to tell her (family member). The Social Worker stated Resident #2 did not feel safe when CNA H was working at the facility. During an interview on 02/16/24 at 2:08 PM with the Administrator, she stated that law enforcement was not notified on 02/02/24. The Administrator stated during the investigation a head-to-toe assessment of Resident #2 was done by LVN F and LVN E indicating no harm to Resident #2. The Administrator stated the facility only contacts the police if there was harm. The Administrator stated both LVN F and LVN E did the body assessment but was only verbally communicated but there was not documentation of the incident or assessment. During an interview on 02/16/24 at 2:26 PM with LVN F, he stated he was never told to do a body assessment on Resident #2. LVN F stated there was no body assessment done on 02/02/24. LVN F stated he would have to have had a physician order or a directive from his DON to conduct the body assessment which there were none of. LVN F stated he was not trained or certified on assessing residents who claim sexual abuse/exploitation. LVN F stated he did not know what to look for. LVN F stated if he was looking for anything it would be bruises or marks on Resident #2. LVN F stated he recommended for Resident #2 to have been sent out to the hospital to have a rape kit done. LVN F stated on 02/13/24 he was told to go assess Resident #2. During an interview on 02/16/24 at 2:39 PM with LVN E, she stated she was never told to do a head-to-toe body assessment on Resident #2 on 02/02/24. LVN E stated she quickly checked Resident #2's thigh and opened up her brief to see if there was any bruises or marks but did not know what to look for as she was not trained or certified to conduct a sexual assessment on a resident. LVN E stated when a resident claims sexual abuse/exploitation that they were sent out to the hospital to go get checked out. LVN E stated on 02/13/24, she was directed to go assess Resident #2. During an interview on 02/17/24 at 5:02 PM with the Regional Nurse, she stated the facility nurses were not trained or certified to do sexual assessments but could assess the resident externally to see if there was any bruises or markings. Record review of the facility's Documentation policy and procedure manual dated 2003 revealed, Documentation was the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has a legal requirement regarding accuracy and completeness, legibility, and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessments, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets weekly, daily, monthly, discharge). Goal- The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. The facility will ensure that information was comprehensive and timely and properly signed. Document completed assessments in a timely manner and per policy. Complete documentation in narrative nursing notes as needed in a timely manner. Daily documentation x72 hours will be required for each shift for new admissions, during and following an acute episode, following an incident, and during physiologic, mental, or emotional changes or instability. Record review of the facility Event Reporting: Completion Of (Regional Nurse stated this was the facility's accident policy) policy and procedure not dated revealed, Investigation: The investigation should be completed by the DON/Administrator or designee. The investigation report documents a though investigation of the events of the reported Event including person, equipment, and materials that were involved. The investigation report must include what actions were taken to prevent subsequent Events and signatures of the individuals as indicated on the form. The facility will complete an Event report on variances that occur with the facility. Variances include falls, skin tears, bruises, abrasions, lacerations, fractures, choking, burns, elopement, or behavior that affects others. Record review of the facility Bath, Tub/Shower policy and procedures dated 2003, revealed, The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level. The resident will experience improved comfort and cleanliness by bathing. Become familiar with type and pattern of bathing, assistance or aids needed, skin condition, presence of dress or casts. Remain with the resident if he was weak or assistance was needed in washing. The Administrator and DON were informed on 02/16/24 at 3:01 PM, that an Immediate Jeopardy (IJ) had been identified and a copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested. 02/16/24 at 5:19 PM - Area Director of operations submitted 1st Plan of Removal. 02/16/24 at 6:27 PM - Facility was notified of the 1st denied Plan of Removal. 02/16/24 at 7:51 PM - Administrator submitted 2nd Plan of Removal. 02/17/24 at 11:12 AM - Facility notified of 2nd denied Plan of Removal. 02/17/24 at 11:50 AM - Administrator was notified of approved Plan of Removal. The Plan of Removal revealed the facility took the following actions: Interventions: One on One in-service on Abuse Reporting with the Administrator, DON, and Social Worker by Area Director of Operation on 2/13/2024 at 4:30 pm Staff working with Alleged perpetrators have been interviewed by ADO. The resident is doing ok; no distress was noted, and the resident was able to voice concerns. The alleged perpetrator was suspended on 2/13/2024 at 4:30 pm, pending the outcome of the investigation. Investigation completed on 2/14/2024. Resident safety surveys were initiated by the social worker on 2/13/2024, and no abuse incidents have been reported. Completion date of 2/13/2024 DON was suspended on 2/16/24 at 4:30 pm, pending the outcome of the investigation. The following in-services were initiated on 2/13/2024 by Administrator/ADO: Any staff member not present or in-service on 2/13/2024 will not be allowed to assume their duties until in-service. o All Staff Abuse/Neglect Abuse/Neglect Reporting Who to Report Abuse/Neglect to All in-serviced staff will need to be able to articulate back on reporting any abuse allegation and to whom to report. Completion date 2/17/2024 o The administrator/designee will assess and monitor understanding by quizzing and providing examples on in-services. New staff will be in service during orientation. Any employees who are allegedly involved in any abuse will be suspended pending investigation. The medical director was notified of the immediate jeopardy situation on 2/16/2024 at 4:40. Monitoring The administrator will report any abuse allegations, investigate, and submit findings to the Area Director and Risk Management for review. The administrator will submit documentation of the investigation with Resident and Staff interviews, as well as weekly follow-up interviews with staff and residents x 4 weeks to ensure resident safety/satisfaction with the outcome of the investigation. The Area Director will monitor abuse allegations reported and check the real-time system, which monitors keywords like abuse x 4 weeks' documentation and PCC for any incidents and accidents. The QA committee will review findings of abuse allegations and investigations monthly and make changes to the system as needed. On 02/17/24 at 11:55 AM Verification phase began with the facility approved Plan of Removal. During an interview on 02/17/24 at 11:57 AM with the Administrator and Area Director of Operations, the Area director of Operations stated on 02/13/24 at 4:30 PM she had already in-serviced the Administrator, DON, and Social Worker regarding Abuse Reporting. The Administrator stated on 02/13/24 at 4:30 PM CNA H was suspended pending the outcome of the investigation for Resident #2. The Area Director of Operations stated on 02/16/24 at 4:30 PM the DON was suspended pending the outcome of the investigation. The Area Director of Operations stated the facility had completed the investigation on 02/14/24, for Resident #2 and was found to be unconfirmed. The Administrator stated on 02/13/24 a Safety Survey of the residents was conducted by the Social Worker and found no abuse incidents had been reported by the residents. The Administrator stated the facility was moving forward with termination of CNA H with unrelated issues to the alleged allegation. The Administrator stated Resident #2 stated she was doing fine, able to voice concerns, and no distress was noted. The Administrator and Area Director of Operations stated on 02/13/24 an in-service was initiated by both Administrator and Area Director of Operations for Abuse/Neglect, Abuse/Neglect Reporting, and Who to report Abuse/Neglect too. The Administrator stated facility staff not present, during the in-service will not be allowed to resume their duties until in-serviced. The Administrator stated on 02/17/24 all in-services provided to facility staff had to be communicate back to the presenter acknowledging they understood what was being in-serviced on. The Administrator stated quizzes were given and examples had to be provided by the in-service-e confirming understanding of the material. The Administrator stated new employees would be in-serviced on during orientation. The Administrator stated all alleged employees involved in an allegation will be suspended pending the outcome of the investigation. The Area Director of Operation stated on 02/16/24 at 4:40 PM the Medical Director was notified of the Immediate Jeopardy, commenting that the facility will have to get better. The Area Director of Operation stated the Administrator was to report any and all allegations of abuse and submit all documentation for investigations conducted which would be reviewed by Area Director of Operations and Risk Management. The Area Director of Operations stated the Administrator was also to submit interviews with staff and residents related to investigations four times a week to ensure safety/satisfaction outcomes. The Area Director of Operations stated the facility system will be checked for key words like abuse four times a week for incidents or accidents that might have happened or have been documented. The Administrator stated an off-cycle Quality Assurance meeting was held on 02/16/24 at 5:00 PM, regarding the Immediate Jeopardy and follow ups will be held monthly to see if adjustments are needed to abuse allegations and investigations. During an interview on 02/17/24 at 12:42 PM with LVN P, he stated, he had received an in-service on abuse. LVN P stated that any kind abuse had to be reported to the Administrator immediately. LVN P stated during the in-service it was talked about the 5 different types of abuses such as emotional, verbal, physical, sexual, and financial abuse to include injuries of unknown origin. LVN P stated that the in-servicer did test his knowledge on the material by asking him questions and giving him a quiz on it. During an interview on 02/17/24 at 12:48 PM with LVN Q, he stated, he received an in-service on abuse and neglect. LVN Q stated as soon as an alleged allegation was made or suspect, it must be reported immediately to the Administrator. LVN Q stated he was asked questions about the in-service he had received and had to answer them. During an interview on 02/17/24 at 12:42 PM with LVN I, she stated, she had received several in-services such as abuse. LVN I stated she was told of the different types of abuses and if she saw or suspected abuse happening who to report it to. LVN I stated she had to report abuse to the Administrator who was the Abuse Coordinator. LVN I stated she was questioned on the in-service like it was a test. During an interview on 02/17/24 at 1:15 PM with MA R, she stated, she was in-serviced on abuse and neglect. MA R stated any suspected or seen abuse had to be report to the Abuse Coordinator which was the Administrator. MA R stated she was questioned on what was in-serviced. During an interview on 02/17/24 at 1:23 PM with ADON G, she stated, she had received an in-service regarding abuse and neglect. ADON G stated they told her what constitutes abuse and neglect and who to report it to. ADON G stated abuse was reported to the Administrator immediately. ADON G stated she was questioned over the in-service(s) of abuse to check her knowledge. During an interview on 02/17/24 at 1:31 PM with CNA T, she stated, an in-service of abuse was given to her. CNA T stated it entailed what abuse was and the different types. CNA T stated she was questioned over the material being presented. CNA T stated any kind of abuse had to be reported immediately to the Administrator. During an interview on 02/17/24 at 1:43 PM with CNA U, she stated, she was in-serviced on abuse regarding the different types of abuse. CNA U stated staff were to report if someone talks bad or physically hits a resident. bad or physically hits them. CNA U stated it had to be reported to the Administrator. CNA U stated she had received a quiz on the in-service. During an interview on 02/17/24 at 1:52 PM with LVN V, she stated, she had received an in-service on abuse and neglect on 02/16/24. LVN V stated to report anything the facility staff felt was abuse and who to report it to. LVN V stated it was to be reported to the Abuse Coordinator which was the Administrator. LVN V stated she was asked questions about what they felt it was reportable and why. Record review of the facility Monitoring Tools dated 02/17/24, revealed, the following: In-Services - The Administrator will audit all new employee filles to ensure in-services are being completed. Ensure Quizzes are being completed - Administrator will gather quiz sheet 3 per day. Record review of the facility In-services dated 02/13/24, 02/14/24, 02/16/24 revealed, the following: Abuse Reporting/Investigation Abuse and Neglect After the Plan or Removal and Monitoring: The Administrator was informed the Immediate Jeopardy was removed on 02/17/24 at 3:35 PM. The facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern as the facility was continuing to monitor it's plan for effectiveness.

Based on record review, and interview the facility failed to ensure residents were provided supervision and assistive devices to prevent accidents for 1 (Resident #1) of 12 residents reviewed for accidents. The facility failed to provide supervision to prevent the elopement of Resident #1. The facility failed to have a monitoring tool in place for when residents were outside in the back patio area. Resident #1 was outside in the back patio area, unsupervised by staff for approximately 34 minutes, and was found near the facility building walking without her wheelchair near a ravine and busy street. An IJ Immediate Jeopardy (IJ) was identified on 02/16/24. The IJ template was provided to the facility on [DATE] at 3:01 PM. While the IJ was removed on 02/17/24, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated as the facility was continuing to monitor it's plan for effectiveness. These failures could place residents at risk for the outside in the back patio are unsupervised of elopement or injuries. Findings include: Record review of Resident #1's face sheet dated 02/09/24, revealed, admission on 09/12/22 to the facility. Record review of Resident #1's most recent facility history and physical in the system dated 09/12/22, revealed, a [AGE] year-old female (present age [AGE] years old) was diagnosed with Alzheimer (a brain disorder that gets worse over time) Dementia ( impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and atrial fibrillation (a type of arrhythmia, or abnormal heartbeat). Record review of Resident #1's quarterly MDS dated [DATE], revealed, Resident #1 made poor decisions and cues/ supervision was required, regarding daily tasks; had wandering behaviors that occurred daily; required a wheelchair for mobilization; had 1 fall with major injury since admit. Resident #1 was on oxygen therapy. Record review of Resident #1's care plan dated 1/19/2024, revealed, she was at a risk for elopement, as evidenced by impaired safety awareness, wanders aimlessly. Supervise closely and make regular compliance rounds whenever resident was in room. Determine the reason the resident was attempting to elope. Was the resident looking for something or someone? Does it indicate the need for more exercise? Intervene as appropriate. Distract resident from elopement attempts by offering pleasant diversions, structed activities, food, conversation, television, books. If the resident was exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. Record review of Resident #1's Elopement Risk Assessment, dated 01/20/2024, revealed she had previous attempts to leave the facility, documented as one or more times in the last week. Record review of the Fall assessment dated [DATE], revealed, she was disoriented x3, at all times, she had 1-2 falls within the past 3 months, she was chair bound, and had balance problems while standing or walking. During an interview on 02/09/24 at 8:50 AM with the Maintenance Director, he stated Resident #1 had eloped from the back patio area and was found near the corner in the parking lot of the facility building. Maintenance Director stated residents are able to go outside to the back patio area that enclosed from 8AM-8PM unsupervised as the back patio black gates were locked with a pad lock. Maintenance Director stated the dining room doors have an alarm system but not the back black gate door as they will only open when the fire door alarm goes off. During an interview on 02/09/24 at 9:58AM, with LVN A, she stated Resident #1 was a wanderer and has a history of elopements. LVN A stated Resident #1 had an elopement on 02/06/24. LVN A stated there were not assessments or document in progress notes or anywhere else until 02/08/24 as DON stated she was going to put the incident information in the system but had not until 02/8/24. LVN A stated residents were able to go outside using the dining area door to go outside in the back patio area due where it was secured (Back patio black gate had a pad lock on it). LVN A stated when Resident #1 had an elopement the door alarm(s) did not sound. LVN A stated Resident #1 was outside the building near hallway 1, at the corner. LVN A stated Resident #1 was crying and had emotional distress and was swinging at the Housekeeper who found her. LVN A stated Resident #1 was standing but had unsteady gait and history of falls. LVN A stated Resident #1 has a wheelchair and staff try to keep her in her wheelchair to prevent falls. LVN A stated she could not remember when the last time was, she had seen Resident #1. LVN A stated there was a risk to Resident #1 being outside of the enclosed back patio area of Resident #1 falling in the ravine and possibly breaking something. LVN A stated the weather on 02/06/24, outside was below 50 degrees with Resident #1 was wearing a jacket and sneakers who was non-verbal. During an interview on 02/09/24 at 10:23 AM, with LVN B, she stated Resident #1 has a history of elopements and had an elopement on 02/06/24. LVN B stated staff responded to Resident #1's elopement and saw her outside the enclosed back patio area near the dumpsters. LVN B stated the Housekeeper found her and was being hit by Resident #1. LVN B stated they were not alerted as the door alarms did not go off. LVN B stated Resident #1 being outside of the enclosed back patio area could have been a risk to her as she could have gotten an injury. LVN B stated she did not know for how long Resident #1 was outside. During an interview on 02/09/24 at 10:42 AM, with the Housekeeper, she stated she went to go throw a trash bag at around 11:00 AM, in the dumpster when she turned around and saw Resident #1 standing up without her wheelchair near the corner of the building near hallway 1. The Housekeeper stated Resident #1's wheelchair was in the back patio area. The Housekeeper stated the sun was out and it was fresh outside. The Housekeeper stated Resident #1 was wearing pants and a blouse with no jacket on and her baby (doll). The Housekeeper stated Resident #1 was hitting her as she tried to assist Resident #1 back to her wheelchair in the back patio area. The Housekeeper stated she could not remember if the back patio door was open or closed. The Housekeeper stated there was a risk to Resident #1 with falling and there was a street nearby and could risk Resident #1 walking into oncoming traffic. The Housekeeper stated there was no door alarm going off to let staff know a resident had left the facility. During an interview on 02/09/24 at 11:04AM, with Housekeeping Director, she stated she received a call form Housekeeper letting her know that Resident #1 was outside of the facility. The Housekeeping Director stated Resident #1's wheelchair was inside the back patio area with the gate door closed. The Housekeeping Director stated she saw the Central Supply going to help out the Housekeeper with Resident #1 who was standing up outside of the enclosed back patio area. The Housekeeping Director stated Central Supply helped Resident #1 get back to her wheelchair. The Housekeeping Director stated there was a risk for Resident #1 knowing she was a in wheelchair and walking she could have fallen and injured herself. The Housekeeping Director stated the door alarms did not go off alerting facility staff that a resident or someone had left the facility. During an interview on 02/09/24 at 11:51 AM, with Central Supply, he stated he heard yelling outside of his office. Central Supply stated Resident #1's wheelchair was stuck in between the gate holding the gate door open. Central Supply stated the Housekeeper was holding Resident #1 between the storage and dumpster 1. Central Supply stated the back patio gate door did not have an alarm and did not hear door alarms going off. Central Supply stated the Housekeeping Director went to go get help while he went to get the wheelchair. Central Supply stated Resident #1 was wearing jeans, sweater or long sleeve (not sure), and shoes. Central Supply stated it was cold and had rained in the morning but was not raining at the time of the incident. Central Supply stated Resident #1 did not look like she had an injury. Central Supply stated there was a risk to Resident #1 of getting hurt. During an interview on 02/09/24 at 1:05 PM, with CNA W, she stated Resident #1 was being bought back into the back patio area on her wheelchair. CNA W stated Resident #1 was wearing a white shirt sweater type of blouse with jeans and pink/white shoes, with her baby (doll) wrapped up in a clothing protector. CNA W stated it was cold and windy at that time and had rained earlier in the day. CNA W stated she did not hear the door alarms going off. CNA W stated when Resident #1 was brought in she had dry clothes. CNA W stated there could have been a risk of Resident #1 wandering off all the way to the street and going into oncoming traffic. CNA W stated Resident #1 had a history of elopements. During an interview on 02/09/24 at 1:20 PM, with SCNA C, he stated the weather was a gloomy overcast with no wetness or rain. SCNA C stated Resident #1 was wearing jeans with a blue wind breaker and white shoes. SCNA C stated Resident #1 does wander off and tries to exit through the exit doors. SCNA C stated Resident #1 has a wandering stance type and her back was off set. SCNA C stated there was a risk and danger of Resident #1 walking into traffic and of fall over the brick wall into the ravine to her death. During an interview on 02/09/24 at 1:46 PM, with Receptionist, she stated Resident #1 was trying to escape all morning with trying to push the front door open and trying to stand up from her wheelchair. The Receptionist stated that LVN A and LVN B told her that Resident #1 was agitated due to receiving a shower and gets like that. The Receptionist stated the facility staff had tried redirecting Resident #1 with getting her drinks and her baby (doll) to calm down but was not calming down. The Receptionist stated the Administrator and DON were also present in the front lobby area and they did not comment on what was going on with Resident #1 being agitated. The Receptionist stated LVN A and LVN B went to talk Resident #1 to her hall but ended up coming back to the dining area. The Receptionist stated at that time in the dining area there were no facility staff present and most of the residents in the dining area were not alert residents. The Receptionist stated she was notified by the Housekeeping Director that Resident #1 was outside of the facility. The Receptionist stated she notified the facility via the intercom of Resident #1 being outside of the facility. The Receptionist stated Resident #1 looked dry and clean. During an interview on 02/09/24 at 2:01 PM, with CNA X, she stated she heard Resident #1 was found outside of the facility by Housekeeper. CNA X stated Resident #1 looked dry and it was cloudy outside. CNA X stated Resident #1 always tries to get up and walk and the facility staff ha to assist her to sit back down on her wheelchair to prevent falls. CNA X stated there was a risk to Resident #1 being outside the facility such as falling and getting hurt. During an interview on 02/09/24 at 2:15 PM, with the Activities Director, she stated she was doing her Champion Rounds (Random untimed hallway rounds that supervisory staff are assigned too to check on the residents) and was not in the dining area. Activities Director stated she did not hear the door alarms ring when Resident #1 eloped from the facility. Activities Director stated she found out due to facility staff talking about Resident #1 being found outside of the facility. Activities Director stated Resident #1 has history of standing up from her wheelchair. Activities Director stated it was fresh outside, cloudy, but not rainy. Activities Director stated Resident #1 could have fall and hurt herself or grabbed a piece of trash from dumpsters or floor. During an interview on 02/09/24 at 2:35 PM, with Assistant Activities, she stated the kitchen guy had told her that Resident #1 was outside if the facility. Assistant Activities stated the activities department was not doing activities during the time Resident #1 had her elopement. Assistant Activities stated Resident #1 was able to walk but with difficult without her wheelchair. Assistant Activities stated Resident #1 was wearing a sweater with tennis shoes and was combed with no injuries noted. Assistant Activities stated there was a risk of Resident #1 falling being outside of the facility. Assistant Activities stated the door alarm did not ring letting facility staff know someone was outside of the facility. Assistant Activities stated the purpose of the door alarms was for the safety and protection of the facility residents and to let the facility staff know when someone was outside. During an interview on 02/09/24 at 2:59 PM, with the Administrator, she stated Resident #1 did not get out of the premises even though Resident #1 exited the enclosed back patio area. The Administrator stated the Housekeeper found Resident #1. The Administrator stated Central Supply heard Resident #1 yelling and went to go help the Housekeeper. The Administrator stated Resident #1 was only outside for minutes but could not confirm this. The Administrator stated Central Supply had seen Resident #1 outside in the back patio area before she had gone outside of the enclosed back patio area. The Administrator stated Central Supply got Resident #1's wheelchair who was standing up and opened the back patio gate and prompted Resident #1 to go ahead and sit down on it. The Administrator stated Resident #1 was at the corner of the building near hallway 1 by the dumpsters. The Administrator stated there was a street near the facility and a ravine. The Administration stated Resident #1 had no steady gait (a pattern of walking that's unstable). The Administrator stated Resident #1 was assessed and was noted not to have any injuries. The Administrator stated she would consider the elopement to be serious in nature (serious problems or situations that are very bad and cause people to be worried or afraid). The Administrator stated that staff did not keep track of residents when they were in the back patio area alone because the back patio black gate was locked with a keypad lock. The Administrator stated the weather outside on 02/06/24 was a high of 50 degrees, fresh, and not raining or windy. The Administrator stated Resident #1 was wearing jeans, a long sleeve shirt, and shoes. The Administrator stated Resident #1 was not wet. The Administrator stated the back patio black gate did not go off as it was not connected to the fire alarm system. During an interview on 02/09/24 at 4:05 PM, with the DON, she stated the Housekeeping Director went to grab her and notified he that Resident #1 was found outside. The DON stated Resident #1 was near the dumpster and back door gate. The DON stated the facility staff already responding to Resident #1 being outside of the back patio area was trying to prompt Resident #1 to sit down on her wheelchair as she was standing up. The DON stated the Housekeeper had told her that she was throwing the trash when she turned around and she Resident #1 standing up at the corner of the building near hallway 1. The DON stated Housekeeper called the Housekeeping Director for help with Resident #1. The DON stated Central Supply heard Resident #1 yelling and went to check it out and found the Housekeeper with Resident #1. The DON stated she was not sure if the facility had placed an alarm on the back patio door gate. The DON stated when residents go to the back patio area alone there were no tools for monitoring the residents to ensure their safety because the back patio black gate was locked. The DON stated she assessed Resident #1 who had not injuries. The DON stated the door codes to the facility where changed, the facility staff were in-serviced to go outside with a resident who wanted or went outside int eh back patio area, and they would have a sign out sheet. The DON stated the alarm did not go off and did not say why it did not go off. During an interview on 02/12/24 at 1:23 PM, with LVN AF, she stated facility residents were allowed to go outside in the back patio area by themselves and there was no monitor tool in place to ensure the residents safety when outside in the back patio area . LVN AF stated if the door alarm goes off the facility staff had to respond to it and check the perimeter of the facility. Observation of on 02/12/24 at 1:30 PM of the facility back patio area revealed that it was enclosed. There were to black gates with keypads. Black gate doors were closed and locked. There was not pad lock with key hooked and door knock. During an interview on 02/12/24 at 1:50 PM, with LVN AH, she stated there was nothing in place to monitor residents when they were in the back patio area left alone. LVN AH stated she was in-serviced on when an alarm door rings and what to do. LVN AH stated when facility staff go outside that they had to make sure the door was shut behind them. During an interview on 02/12/24 at 3:18 PM, with the Administrator, she stated the door codes were switched out. The Administrator stated the only staff who had the codes to the back patio gate was the Administrator and the Maintenance Director. The Administrator stated the facility staff were in-service on 02/09/24 on not leaving residents alone outside in the back patio area and had to be monitored. The Administration stated the facility staff were also in-serviced with not sharing the door codes with family, visitors, or residents. During an interview on 02/15/24 at 10:28 AM, with ADON G, she stated there was no monitoring tool in place for residents who went to the back patio area alone. ADON G stated there could be a risk of elopement, injury, and anything because there was no way to monitor the residents when they were outside in the back patio area alone. During an interview on 02/15/24 at 3:48 PM with the Medical Director, he stated he was notified of Resident #1's elopement. The Medical Director stated Resident #1 needed to have her wheelchair as she was demented and had multiple falls in the past where she broke her shoulder. The Medical Director stated Resident #1 would have benefited from using the wheelchair. The Medical Director stated having any resident that was demented outside could be a risk of hurting themselves. The Administrator and DON were informed on 02/16/24 at 3:01 PM, that an Immediate Jeopardy (IJ) had been identified and a copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested. 02/16/24 at 5:19 PM - Area Director of operations submitted 1st Plan of Removal. 02/16/24 at 6:27 PM - Facility was notified of the 1st denied Plan of Removal. 02/16/24 at 7:51 PM - Administrator submitted 2nd Plan of Removal. 02/17/24 at 11:12 AM - Facility notified of 2nd denied Plan of Removal. 02/17/24 at 11:50 AM - Administrator was notified of approved Plan of Removal. The Plan of Removal revealed the facility took the following actions: Interventions: All present facility staff were in-serviced by the Administrator/ADO on the following: o No residents to be left unsupervised in the patio area. Completion date: 2/16/2024 o Maintenance Director/Designee will ensure that the back door leading to the patio area is closed at all times and a code to enter and exit the building. Completion date: 2/16/2024 o Staff will not share the code with residents. Completion date: 2/16/2024 All staff not in service on 2/16/2024 in person or on the phone will be in service before the start of their shift to be completed and monitored by the facility administrator/ADO. On 2/7/24, the maintenance director of the facility did the following: o Changed the patio gate code. o Changed the back door leading to the patio area code. New staff will be in service during orientation. The medical director, was notified of this plan on 2/16/2024, and an off-cycle QAPI plan was initiated regarding this event, with a completion date of 2/16/2024 at 5 pm. This affected Resident #1 and had the potential to affect 27 other residents with wandering/exit-seeking behaviors. Monitoring: The Maintenance Director/Designee will monitor Monday-Friday and Maintenance Assistance will monitor weekends the patio daily to ensure no unsupervised residents are on the patio. On 02/17/24 at 11:55 AM Verification phase began with the facility approved Plan of Removal. During an interview on 02/17/24 at 11:57 AM, with the Administrator and Area Director of Operations, the Administrator stated the present facility staff were in-serviced regarding, No Residents to be left unsurprised in the patio area. The Area Director of operations stated all facility staff not present were called and in-serviced regarding, No Resident to be left unsurprised in the patio area. The Administrator stated all facility staff were in-serviced by 02/16/24. The Administrator stated facility staff not present, during the in-service will not be allowed to resume their duties until in-serviced. The Administrator stated the Maintenance Director was in-serviced with monitoring the facility doors Monday-Friday to ensure they were closed, every 2 hours and to change out the code (not share it). The Administrator stated the Area Director of Operations will be using a monitoring tool to ensure the Administrator and Maintenance Director were checks the facility doors every 2 hours. The Administrator stated on 02/17/24 all in-services provided to facility staff had to be communicate back to the presenter acknowledging they understood what was being in-serviced on. The Administrator stated quizzes were given and examples had to be provided by the in-service-e confirming understanding of the material. The Administrator stated new employee would be in-serviced on during orientation. The Area Director of Operation stated on 02/16/24 at 4:40 PM the Medical Director was notified of the Immediate Jeopardy, commenting that the facility will have to get better. The Administrator stated the facility had 27 wandering/exit seeking residents who were audited and will have assessments and care plans updated for each. During an interview on 02/17/24 at 12:42 PM, with LVN P , he stated, he had received an in-service on the door alarms. LVN P stated the facility staff were to respond to door alarms going off, do a head count of the residents, and check the outside of the facility for any resident(s). LVN P stated another in-service was to not leave residents outside in the back patio area alone. LVN P stated during the in-service it was asked, What do you do if a resident was seen outside in the back patio area by themselves? and it had to be answered. LVN P stated that the in-servicer did test his knowledge on the material by asking him questions and giving him a quiz on it. LVN P stated they were also in-serviced with not sharing the code with visitors or residents. During an interview on 02/17/24 at 12:48 PM, with LVN Q, he stated, he received an in-service on not leaving a resident outside alone in the back patio area. LVN Q stated that a facility staff member had to be with the resident at all times outside. LVN Q stated they were told not to share the code with family or residents. LVN Q stated he was asked questions about the in-service he had received and had to answer them. During an interview on 02/17/24 at 12:42 PM, with LVN I, she stated, she had received several in-services such as not leaving a resident unattended outside in the back patio area. LVN I stated she was in-serviced on door alarms. LVN I stated she had to respond to door alarms as soon as they went off. LVN I stated a code orange had to be called if a resident was missing for more than 30 minutes, a head count had to be done, and the police notified. LVN I stated they were in-serviced not to share the codes with visitors, family, and residents. LVN I stated she was questioned on the in-service like it was a test. During an interview on 02/17/24 at 1:15 PM, with MA R, she stated, she was in-serviced on the facility doors having to be closed when they or someone exits. MA R stated that she was in-serviced on not leaving a resident alone in the back patio area and a staff had to be with them. MA R stated she was questioned on what was in-serviced. During an interview on 02/17/24 at 1:23 PM, with ADON G, she stated, she had received an in-service on not leaving a resident outside alone in the back patio area. ADON G stated if a resident was outside the facility staff would have to immediately go outside and be with the resident. ADON G stated she was in-serviced on not giving the code to the residents, family, and visitors. ADON G stated she did not have the code to the back patio gate. ADON G stated she was questioned over the in-service(s) of not sharing the codes, closing the exit doors behind them, and not leaving a resident alone outside by themselves to check her knowledge. During an interview on 02/17/24 at 1:31 PM, with CNA T, she stated, an in-service of not sharing the door codes with residents nor family or visitors. CNA T stated resident could not be left alone outside in the back patio area and a staff had to be with them when outside. CNA T stated she was questioned over the material being presented. During an interview on 02/17/24 at 1:43 PM, with CNA U, she stated, she was in-serviced on when residents were in the back patio area. CNA U stated if residents want to go outside then a staff member had to go outside with them. CNA U stated if a resident was seen outside alone then the staff would have to go outside and stay with the resident until relieved or the resident came inside. CNA U stated she had received a quiz on the in-service. During an interview on 02/17/24 at 1:52 PM, with LVN V, she stated, she had received an in-service on residents could not be alone in the back patio area. LVN V stated facility staff had to go outside and stay with the resident. LVN V stated the exit doors had to be closed if a staff went outside and they had to ensure it was closed. LVN V stated she was in-serviced on not sharing the code with family, residents, or visitors. LVN V stated she was asked questions about the in-services. Observation on 02/17/24 at 2:32 PM, heard and saw facility staff checking the door alarms in the back dining area. Maintenance Director was seen going to each hallway and inspecting each door and making sure the door alarms rang. Record review of the facility Monitoring Tools dated 02/17/24, revealed, the following: Change back gait code do not share with staff Staff will not share the code with residents or families or visitors The back door leading to the patio area was to be closed at all times, a code was needed to enter and exit the building No resident was to be left unsupervised in the patio area Record review of the facility Monitoring Tools dated 02/17/24, revealed, the following: Monitoring Backdoor Patio Door - Maintenance Director will monitor the back door every 2 hours during the day Monday-Friday for a week, then daily for a week, then randomly. Monitoring Chart (Patio Door) - Frequency of monitoring: Every 2 hours. In-Services - The Administrator will audit all new employee filles to ensure in-services are being completed. After the Plan or Removal and Monitoring: The Administrator was informed the Immediate Jeopardy was removed on 02/17/24 at 3:35 PM. The facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility's need to reevaluate the effectiveness of the corrective systems that were put into place.

Based on observation, record review, and interview the facility failed to ensure residents were provided supervision and assistive devices to prevent accidents for 2 of 10 (Resident #1 and Resident #12) residents reviewed for accidents. The facility failed to provide supervision to prevent the elopement of Resident #1. Staff failed to respond to the door alarm when the resident exited the facility. Resident #1 was outside, unsupervised by staff for approximately 1 hours, and suffered lacerations and abrasions. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/19/24. The IJ template was provided to the Administrator. The IJ was removed on 01/20/24, but the facility remained out of compliance at a scope of actual harm and severity level of isolated because the facility failed to have a system in place to ensure residents are monitored when facility door alarms sound off. The facility failed to conduct safe transfers for Resident #12, CNA F did a one-person transfer with Hoyer lift. These failure could place residents at risk of harm and injuries due to lack of supervision and failure to follow protocols. Findings include: Resident #1 Record review of Resident #1 ' s face sheet dated 01/19/24 revealed admission on 11/20/23 to the facility. Record review of Resident #1 ' s facility history and physical dated 11/20/23 revealed a [AGE] year-old male diagnosed with anoxic brain injury (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation), mental illness (disorders that affect your mood, thinking and behavior), and cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body). Record review of Resident #1 ' s admission MDS dated [DATE] revealed a moderately cognitive impairment to be able to recall and make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 7. Resident #1 had a behavior of wandering. Activities of daily living revealed Resident #1 to be independent with eating, oral hygiene, toileting, dressing, toilet transfers, sit to stand, lying to sitting on side of bed, and be able to walk 150 feet but only 10 feet on uneven surfaces. Resident #1 was diagnosed with Coronary Artery Disease (caused by plaque buildup in the wall of the arteries that supply blood to the heart), Seizure Disorder (abnormal electrical brain activity), anoxic brain damage, cardiomyopathy, and lack of coordination (Uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements), muscle weakness (no muscle strength), and cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of Resident #1 ' s care plan dated 12/06/23 [sic] revealed at risk for elopement as evidenced by anoxic brain damage. Assess/record/report to medical doctor risk factors for potential elopement such as - wandering. Repeated request to leave facility, statements such as, I ' m leaving (no date was indicated for this comment), I ' m going home (no date was indicated for this comment), attempts to leave facility, elopement attempts from previous facility. Supervise closely and make regular compliance rounds whenever resident was in room. Determine the reason the resident was attempting to elope. Is the resident looking for something or someone? Does it indicate the need for more exercise? Intervene as appropriate. Resident #1 was at risk for wandering. Impaired safety awareness. Assess for fall risk. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? If a resident was exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. Resident #1 was on anticoagulant therapy. Avoid activities that could result injury. Take precautious to avoid falls. Record review of Resident #1 ' s Elopement Risk assessment dated [DATE] revealed high risk for elopement score of 12. Moderately impaired - decision poor, cues/supervision required. Elopement was signed and locked on 11/30/23 instead of being locked on 11/20/23 when Resident #1 was admitted to facility. Record review of Resident #1 ' s Elopement Risk assessment dated [DATE] revealed high risk for elopement score of 11. Moderately impaired - decision poor, cues/supervision required. It was unknown why an elopement assessment was conduct as Resident #1 was no longer returned to the facility. Record review of Resident #1 ' s Fall Risk assessment dated [DATE] revealed a moderate score of 8. Resident #1 had intermittent confusion. Record review of Resident #1 ' s Order Recap dated 11/20/23 revealed on anticoagulant - monitor for bruising, nosebleeds, for prolonged bleeding from wound. Review of weather records for 11/30/23 between 6:15 am to 7:45 am, the temperature was 51-53 degrees Fahrenheit, there was light rain, and wind gusts from 30 to 37 miles per hour. [https://www.wunderground.com/history/daily/us/tx/el-paso/KELP/date/2023-11-30 accessed 2/2/24]. Record review of Resident #1 ' s progress notes written by LVN A dated 11/30/23 revealed, at 8:30 am - As per nursing 06:00 am staff CNA (unidentified) noticed resident was not in his room. Checked on dining room and receptionist where resident always stays. Code orange elopement) was activated. Family, DON, Administrator, police department, medical doctor notified. 10:04 am - As per 6am CNA staff started doing rounds and got into patient room later around 7:00 am. Record review of sister facility ' s progress notes dated 11/30/23, where Resident #1 transferred, following the elopement, revealed Resident arrived via car accompanied by family member at 10:00 AM. According to family member he eloped from previous facility and was found wandering streets in the Westside of the city until he was picked up by the police. Police then transported Resident #1 to a family member residential address that he remembered. Family member was then contact and picked up Resident #1 and bought him here. Resident #1 looked disheveled (things other than hair that have a messy or untidy appearance) in appearance. Walking in socks because his shoes were still wet from the rain. Head to toe assessment - laceration and abrasion noted to facial area/upper right brow/forehead. Large dark discoloration to left side of ribs. Record review of Resident #1 ' s skin assessment from sister facility dated 11/30/23 revealed Resident #1 with the following: a dark painful bruise to left side of ribs 14cm by 9cm. Right pinky finger with a skin tear 0.3cm by 0.3cm. Right side abrasion above upper brow 6cm by 5.5cm. Right cheek abrasion 2cm by 2cm. Left palm abrasion 5cm by 4cm. Right palm abrasion 7cm by 4cm. Left knee abrasion 3.5cm by 3.5cm. Right knee abrasion 6cm by 3.5 cm. Left top of foot abrasion 4.5cm by 2cm. Right elbow abrasion 2cm by 2cm. Right side laceration above upper brow 0.5cm by 0.5cm Left side laceration near orbital 1cm linear laceration. Right side of sacral area laceration, crescent shaped 0.5cm. Skin findings - redness to neck and chest Record review of the x-ray conducted, by the sister facility, after the resident transferred from this facility, of Resident #1 dated 11/30/23 revealed X-Ray to right rib status post fall, pain, bruising. Findings: Multiple radiographs of ribs were obtained. They show no fracture or other focal bony abnormality. There was no evidence for pneumothorax (a collapsed lung), pleural effusion (an unusual amount of fluid around the lung), pleural thickening (develops when scar tissue thickens the delicate lining around the lungs (the pleura) or pulmonary contusion (an injury to the lung parenchyma in the absence of laceration to lung tissue or any vascular structures). The view of the chest shows no abnormality area. Record review of the Resident #1 ' s Event Note dated 11/30/23 revealed, As per nursing, 06:00AM - staff CNA noticed resident was not in his room. Checked on dining room and receptionist area where resident likes to stay. Code Orange was activated. Family, DON, Administrator, police department, medical doctor was notified. Note What door exited - Unknown Note How long missing - Unknown Record review of city streets on google maps dated 01/19/24 revealed near the facility was a busy two-way intersection (265.24 ft away) with a speed limit of 35 miles per hour. Further up the street near the facility was another four-way busy intersection (1,222.46 ft away) with a speed limit of 45 miles per hour. Record review of facility 3613-A that was submitted to state agency dated 12/07/23 revealed - Timeline - 5AM resident was seen in his bed asleep 5:30 AM resident was given his morning medications 5:40 AM CNA observed resident walking around his room 6:15 AM LVN heard back door alarm going off, she run to check and did not see anyone. 6:25 AM Construction workers saw an old man walking around the parking lot, did not mention anything since they did not know he was a resident of the facility. 6:35 AM Code Orange was initiated. Staff searched the premises and nearby stores and gas stations. 7:12 AM EPPD notified of a missing person 7:45 AM EPPD took resident to mothers 8:45 AM resident arrived at sister facility and rehab Transferred to sister facility as per family Record review of Detective e-mail dated 01/22/24 revealed Resident #1 was found at 7:50 AM on local retailer 1.29 miles (2.08 km). Resident #1 was alert and the weather was unknown at that time. During an observation and interview on 01/19/24 at 10:36 am, Surveyor A and Administrator opened hallway 1 exit door for alarm to ring. LVN K and CNA L responded to door alarm. No administrative staff were observed responding to the door alarm. LVN K stated when exit door alarm rings she was to open the door and check the outside premises to ensure no residents were observed outside. LVN K stated she would then do a head count and ensure all her residents were accounted for and notify DON. During an interview on 01/19/2024 at 10:43 am, LVN K stated when exit door alarms ring all staff were expected to respond to the exit door and assist to include housekeeping, CNAs, nurses, and administration staff. LVN K stated the lack of response from staff when door alarm rang was concerning. LVN K stated only her and CNA L responded to the door alarm. LVN K stated she had 5 CNAs on that side of the building. LVN K stated she knew 2 CNAs were busy with changing residents, CNA K responded, was not aware of CNA S whereabouts and CNA R was out on break. During an observation and interview on 01/19/24 at 11:13 am, SW office was the closest office to hallway 1. The SW denied hearing a door alarm ring. During an interview on 01/19/23 at 11:00 AM with the Administrator, she stated she was notified of Resident #1 missing from ADON E at 6:50 AM, in which the nursing staff could not find him. The Administrator stated she had instructed ADON E to check all the rooms in the facility. The Administrator stated a CNA went in Resident #1 ' s room to get him up for the day and could not find him. The Administrator stated she had informed the ADON E that she would start looking outside when she got to the facility. The Administrator stated Resident #1 did not have a history of elopement in their facility and the past facility he came from. The Administrator stated Resident #1 did not have a wander guard as the facility was a wander guard free facility. The Administrator stated the local police department did not give the facility the police report of Resident #1 and did not know why. The Administrator stated the back door leading to the back patio was going off in the morning around 6 AM. The Administrator stated LVN A responded to the door and turned off the alarm. The Administrator stated LVN A looked outside and saw no one and other staff members responded but once seeing LVN A had responded turned around and went back to their work areas. The Administrator stated the facility staff did not do a perimeter check around the facility. The Administrator stated it was not documented that a head count was conducted to make sure no other residents were missing. The Administrator stated it was expected for facility staff to respond immediately to door alarms and check to see what was going on or if anybody needed assistance. The Administrator stated she in-serviced the facility staff in regard to whenever a door alarm goes off that facility staff have to respond and not go back to what they are doing. The Administrator stated Resident #1 exited through the back door. The Administrator stated the facility implemented other interventions such as shortening the front door lock from 30 seconds to 15 seconds, changing the code on the doors, and conducting audits on residents with elopement. The Administrator stated the facility made every effort to prevent elopement. The Administrator stated as per their facility Elopement Prevention policy the facility did not think about placing all their wandering residents in the same hallway. During an observation and interview on 01/19/24 at 11:17 am, Surveyor B opened exit door on hallway 2 (furthest away from receptionist/ dining room area) for alarm to ring. Administrative staff offices were by the receptionist and dining room area. Surveyor A could faintly hear the door alarm ringing. No Administrative staff responded to door alarm. The Receptionist denied hearing a door alarm ringing. During an interview on 01/19/24 at 1:33 PM with Sister Facility Administrator, he stated Resident #1 was readmitted to his facility. Sister Facility Administrator stated the family bought Resident #1 to the facility. Sister Facility Administrator stated the facility had photos of Resident #1 having bruises to the right side of face and bruises to hands/knees and ribs. Sister Facility Administrator stated a skin assessment was conducted. Sister Facility Administrator state the local police found Resident #1 and took him to his family member place. Sister Facility Administrator stated Resident #1 was soaking wet due to it raining outside. Sister Facility Administrator stated the facility had x-rays and results were negative for fractures. During an interview on 01/19/24 at 2:23 PM with Police Officer, he stated a call was placed by the facility on 11/30/23 at 7:43 AM reporting a missing person. Police Officer stated Resident #1 was found at 7:50 AM. Police Office stated when missing persons are reported the officer responding was to create a report if they had sustained any injuries even if it was weather related. Police Officer stated there was not one made for this case. Police Officer stated could be possible he could be okay. Police Officer stated it did not indicate where the resident was found and he appeared okay. Police Officer stated Resident #1 was taken home. During an interview on 01/19/24 at 3:08 PM with LVN A, she stated the day of the incident with Resident #1 the back door alarm was going off. LVN A stated she came in at 6:00 AM and it was going off. LVN A stated the back patio fence doors were not open. LVN A stated she turned off the back door alarm and did not see a Receptionist posted near the front entrance door, which was opposite of the back. LVN A stated she checked that no one was outside. LVN A stated LVN Q looked in the front entrance and did not see anyone. LVN A stated as soon as the missing person was announced the nursing staff all jumped in to help and search. LVN A stated she did not let the other nurses know that they needed to do a head count, but all of her residents were accounted for. LVN A stated the alarm went off and after the alarm went off she did her head count. Record review of Family Members photos of Resident #1 dated 01/24/24, taken when Resident #1 was brought to their house, by police, revealed bleeding abrasion(s) to Resident #1 ' s right upper brow and right cheek, scrapes or scratches to both left and right knees, red marks. Record review of facility training dated 01/19/24 When exiting be aware of surroundings, wait until door was locked to step away in-service not dated revealed it was given and signed by facility staff. Record review of facility training Do not share door code with residents/family members not dated revealed it was given and signed by facility staff. Record review of facility training Changing door code every 2 weeks not dated revealed it was given and signed by facility staff. Record review of facility Remodel area Window door check for Hall 1, 2, 3, 4, 5, 6 dated September, October, November with no year revealed dates and times. Record review of facility Assessment Scoring Report sheet dated 01/01/20-01/01/19/24 revealed 30 facility residents at risk of elopment. Record review of the facility Elopement Prevention policy dated 01/2023 revealed, Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for resident who are at risk elopement. If a resident was discovered to be missing, a search shall begin immediately. (See policy entitled Elopement Response.) Use door locks that are out of reach/sight to prevent wanders from opening doors. Use door alarms or monitoring devices to notify staff when residents try to leave the facility. Consider putting wandering residents on the same unit with a single exit near the nursing station. If applicable, consider the resident for a secured unit. Physical Plant: All facility exits that residents have access to will have a device in place to alert staff of elopement attempts. Wander guard System Keypad exit magnetic locks Keyed Alarms Secured Unit Staff Training: Staff will receive training during their orientation process and then annually regarding - Elopement prevention, Operation of all exit devices, and Actions to take if elopement occurs. Record review of the facility Elopement Response policy dated 10/27/10 revealed, Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or was suspected, our elopement response plan will be immediately implemented. Should an employee discover the resident was missing from the facility, he/she should: Make a thorough search of the building(s) and premises. Make an extensive search of the surrounding area. If unable to locate resident in the building, proceed as follows: After 30-minutes, if the resident has not been found, the following calls must be made: Report missing resident to the police. Post return resident evaluation and care: The facility will evaluate its elopement prevention program and all residents will be reassessed for elopement risk. Record review of the facility elopement Drill or Actual Elopement Guide and in-service dated 04/10/23, 06/29/23, and 10/31/23 revealed, Instruction: elopement drills should be conducted monthly on different shifts at random times. The facility Administrator only provided these 3 in-services and failed to produce the other months as indicated to be done monthly. Time how long it takes staff to begin looking and realize the resident/mascot cannot be found and initiate the elopement plan. Evaluate the actions of the staff and the efficiency of the elopement plan. Report the findings to the QAPI committee. Record review of the facility Preventive Strategies to Reduce Fall Risk policy dated 10/05/16 revealed, Policy: The goal of fall prevention strategies was to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident ' s mobility. Record review of the facility Assessment Scoring Report dated 01/01/20-01/19/24 revealed 30 resiudents with elopement risk. Incident Reporting - Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident(s). The Administrator and DON were informed on 01/19/24 at 4:40 PM that Immediate jeopardy (IJ) had been identified and copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested within the hour. The following Plan of Removal submitted by the facility was accepted on 1/20/2024 at 10:16 am. The Plan of Removal revealed the facility took the following actions: Starting 1/19/24, facility staff were in-serviced by the DON/ADON on the following: All active employee during shift where alarm is heard should Immediately respond to alarm and check the surrounding external areas when alarm goes off. Charge nurses are responsible to do a head count when the door alarm goes off. The head count will be completed within 15min. If resident is not accounted for, charge nurse will initiate code orange. The nurse will complete the head count and document on facility system, 24-hour report, and will report to the administrator. If all residents are accounted for charge nurse will page overhead speaker, code orange all clear. Installation of stop alarms will be completed by 1/19/24 by 8:00pm and alarms will be on, ON mode, at all times. Stop alarms were tested upon installation by Maintenance director to ensure that it is audible throughout the facility including dining room and offices. New staff/Agency staff will be educated during orientation. All staff not in-service on 1/19/2024 in person or on the phone will be in-serviced before the start of their shift. On 1/19/24, the maintenance director of the facility did the following: Stop alarms are being installed by 1/19/24 by 8:00pm in all exit doors to ensure the alarm sound is loud enough to reach offices and dining rooms. The medical director was notified of this plan on January 19, 2024, and an off-cycle QAPI plan was initiated regarding this event, completion date 1/20/24 9:00 am This affected Resident #1 and had the potential to affect 30 other residents with wandering/exit seeking behaviors, Residents are identified by the Elopement risk assessment in facility system. Monitoring: The DON and/or designee will monitor that headcount, outdoor checks, and sign-out sheets are used properly and completed at least five times per week. The administrator, DON, and/or designee will do elopement drills weekly to ensure staff are responding immediately to door alarms. Maintenance director/designee will be responsible for testing alarms 2 times a week to ensure alarms are working properly. Interviews, observations and Record Review to confirm implementation of the Plan of Removal were conducted as follows: Observations on 01/20/2024: 10:16 am, admin opened door to hallway 3. CNA U, 2 staff from down the hallway in hallway 1 respond. CNA W and CNA G, 2 maintenance personnel in the hallway looked over to door. 10:20 am, admin opened hallway 6 alarm. CNA I, Housekeeping Aide, HR, LVN X, Transportation Aide, LVN Y, and CNA F responded. 10:25 am, hallway 1 door was pushed alarm went off. LVN M, CNA U, CNA W, CNA Z, Housekeeping Aide, SCNA BB, and Maintenance Assistant all responded immediately within 5 seconds of pushing the exit door. 10:27 am, hallway 1 door was pushed alarm went off. Could hear in reception SW responded and receptionist was with family but notified Administrator. 10:38 AM - Maintenance Director turn on the alarm system and the doors in the hallway closed and exit doors opened. Facility staff were seen responding from all over the facility. Charge nurses were seen taken head count of the residents. An all clear was given after the head count was taken. Interviews on 01/20/24: CNA I, Housekeeping Aide, HR, LVN N, LVN X, Transportation Aide, LVN Y, CAN F confirmed in-services provided regarding code orange, response to exit door alarms, assist with head count, search outside premises/perimeter to ensure no residents were found outside, police notification, stated they could identify elopement risk residents in PCC and/or elopement binders that were located in nurses station and receptionist area. During an interview on 01/20/24 beginning at 10:30 AM with CNA I, Housekeeping Aide, HR, LVN N, LVN X, Transportation Aide, LVN Y, CAN F confirmed in-services provided regarding code orange, response to exit door alarms, assist with head count, search outside premises/perimeter to ensure no residents were found outside, police notification, stated they could identify elopement risk residents in PCC and/or elopement binders that were located in nurses station and receptionist area. During an interview on 01/20/24 at 11:30 AM with ADON E, she stated she had worked the night shift on 01/19/24 and was in-serviced with the door alarm response. ADON E stated it was procedures to responding to the door alarm soundings. ADON E stated when the door alarms sounds then everyone had to respond to the door that was alarming. ADON E stated facility staff where to also go outside and check the perimeter of the facility to see of there were any residents outside. ADON E stated the nurses were to conduct a head count of all the residents to ensure they were all in the facility. ADON E stated if all residents were accounted for then an all clear could be call, if not then a Code Orange (Indicating Elopement) would have to be initiated. ADON E stated if the resident was not found within 30 minutes, then the local police would have to be notified. During an interview on 01/20/24 at 11:58 AM with CNA T, she stated she was in-serviced on when the door alarm goes off the facility staff have to rush to the door that ' s sounding. CNA T stated two or three staff have to go outside and search the surrounding areas of the facility. CNA T stated if the resident was not found then they call a Code Orange (Indicating Elopement) and the Administrator gets notified. CNA T stated a head count was to be done by the nurses. CNA T stated after 30-minutes of looking for the missing resident then the facility staff call the police. CNA T stated if the resident was found then the nurse gets notified and an all clear gets called. During an interview on 01/20/24 at 11:58 AM with the DON, she stated when a door alarm goes off the nurses need to conduct a head count of all the residents to ensure they are all accounted for. The DON stated when a door alarm goes off all staff are to respond to the door alarm that was going off. The DON stated staff are to search the perimeter for any residents. The DON stated the managers will be responsible for ensuring the nurses are doing the head count of the residents. The DON stated the nurses will also review the sign in/out sheets to make sure the residents are accounted for and the DON and ADONs will oversee that the nurses are doing the checks. The DON stated Maintenance Director will check the outdoor combination locks. The DON stated there was a check sheet for maintenance checking the outdoor combination locks. The DON stated the Administrator, and the DON will be in charge of conducting the Elopement Drill every week with the assistance of an alert resident or a stuff animal. The DON stated the focus of the elopement drill was to check for staff response and timing. During an interview on 01/20/24 at 12:28 PM with the Administrator, she stated the DON will ensure that nurses are doing a head count when a door alarm goes off. The Administrator stated there was a spread sheet that was created to document the headcounts. The Administrator stated the outdoor checks are when the facility staff go outside and check the perimeter of the facility to see if there are any residents. The Administrator stated her, and the DON were responsible for checking the headcount and outdoor checks on the spread sheet to ensure the staff are doing the headcount and outdoor checks. The Administrator stated the elopement drill were to be conducted weekly on different times and days. The Administration stated they were looking to see the response time and how staff work together with deflating task with the elopement drill. The Administrator stated these drills will be record on the Elopement Drill Form. The Administrator stated the Maintenance Director will checking the door alarms to make sure they are working properly (making sure they are ringing) and will be recorded on a sign on/off sheet. The Administrator stated the sheets will be turned in at the end of each week for her to review. Record review of facility in-service dated 01/19/24 revealed it was given and signed by facility staff The in-service indicated when a door alarm goes off, charge nurse are responsible to do a head count within 15 minutes if resident not accounted for. Charge nurse will initiate Code Orange Record review of facility in-service dated 01/19/24 revealed it was given and signed by facility staff. The in-service indicate the nurse will complete the head count and document on facility system, 24-hours report, and will be reported to the administrator. Record review of facility in-service dated 01/19/24 revealed it was given and signed by facility staff. The in-service indicate If all residents are accounted for change nurse with page overhead speaker, code orange all clear Record review of facility Call police after 30-mintues of resident missing in-service dated 01/19/24 revealed it was given and signed by facility staff. Record review of facility Check and walk the perimeter when a door alarm goes off in-service dated 01/19/24 revealed it was given and signed by facility staff. Record review of facility Immediate/Quick response on door alarms in-service dated 01/19/24 revealed it was given and signed by the facility staff. The IJ was removed on 01/20/24, but the facility remained out of compliance at a scope of actual harm and severity level of isolated because the facility failed to have a system in place to ensure residents are monitored when facility door alarms sound off. Resident #12 Record review of Resident #12 ' s face sheet dated 01/19/2024 revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of muscle weakness, unsteadiness to feet, and rheumatoid arthritis (chronic inflammatory disease that affects the joints, this results in painful joints, swelling and stiffness in the joints). Record review of Resident #12 ' quarterly MDS assessment dated [DATE] revealed a BIMS score of 12, he was cognitively intact. Functional abilities and goals section revealed transfers was marked as not applicable- not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. Record review of Resident #12 ' s care plan dated 11/13/23 revealed a focus area for ADL self-care performance deficit related to functional impairment with interventions for transfer that required 2 staff participation with transfers. Record review of incident reports from July 2023- January 2024 revealed no injuries related to transfers identified. During an observation on 01/19/24 at 9:59 am, Resident #12 ' s room door was left opened, CNA F was observed lifting Resident #12 from the bed using the Hoyer lift, brakes were taken off and then moved to be placed over his wheelchair. CNA F placed Resident #12 over his wheelcha [TRUNCATED]