Every finding on record at Hansford County Hospital District dba Lakeridge Nu

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming, and personal hygiene for 1 of 7 residents (Resident #1) reviewed for ADL care.The facility failed to ensure Resident #1 was cleaned of bowel movement and urine on 5/10/2026 and on 5/11/2026.This failure could place the residents at risk for skin breakdown, infection and poor self-esteem.The findings include:Record review of Resident #1's face sheet revealed an [AGE] year-old female originally admitted to the facility on [DATE]. Resident #1 had a medical history of cerebral ischemia (lack of blood flow deprives the brain of vital oxygen and glucose) , unspecified dementia (when a patient exhibits clear signs of cognitive decline such as memory loss, impaired reasoning, or personality changes severe enough to affect daily life), encounter for attention to other artificial opening of urinary tract (management, cleansing, or changing of surgical urinary appliance such as a Urostomy (a surgical procedure that creates an alternate route for urine to exit the body)), muscle weakness and need for assistance with personal care.Record review of Resident #1's admission MDS dated [DATE], indicated in Section C- Cognitive patterns revealed a BIMs score of 4 which indicated Resident #1 had severe cognitive deficits. Section GG- functional abilities revealed Resident #1 was depended for personal hygiene, toileting, and shower/bathing. Section E- Behavior Section E0800 Rejection of care- Presence and Frequency revealed Did the resident reject evaluation or care (.ADL assistance) that is necessary to achieve the resident's goals for health and well-being? 0. Behavior not exhibited. Section H- Bladder and Bowel Appliances revealed resident had a urinary ostomy (a surgically created opening in the abdomen that bypasses the natural intestinal or urinary tract) and resident was always incontinent of bowel.Record review of Resident #1's care plan focus dated 4/22/2026 revealed [Resident #1] have an ADL self-care performance deficit r/t [related to] dementia. [Resident #1] will maintain my current level of function through the review date.provide supportive care. Care plan focus dated 5/05/2026 revealed [Resident #1] continuously removed clothes and urostomy bag, Monitor behavior episodes and attempt to determine underlying cause. Care plan focus dated 5/11/2026 revealed [Resident #1] REMOVED FECES FROM HER BRIEF SMEARED IT, WHEN STAFF ATTEMPTED TO REDIRECT PT [patient] BECAME AGITATED AND PHYSCIALLY AGGRESSIVE. The resident will have no evidence of behavior problems (smearing feces and becoming physically aggressive) . Anticipate and meet the resident's needs.Record review of grievance report dated 5/10/2026 by Resident #1's family member revealed Nature of complaint: Family came in on 5/10/2026 and [Resident #1] had dried feces (a solid or semi-solid waste material expelled from the body through the rectum and anus during defecation) on hands, vaginal area and buttocks.How the complaint was investigated: Interviewed staff.Findings of investigation: Resident hitting and aggressive refusing to allow staff to provide care.Solution: Family notified.Record review of Resident #1's progress notes dated 5/10/2026 at 7:39am revealed This nurse [LVN A]. was notified by CNA [unknown] that [Resident #1] family was in room and [family member] wanted to speak to a nurse [LVN A]. This nurse [LVN A] entered room and [Resident #1] appeared to have been playing in feces prior to family arriving. [Resident #1 family] states I am not mad at you or your staff but [Resident #1] had to have done this sometime last night. Look at how hard this poop is on her hands and body. This nurse [LVN A] assessed [Resident #1]; [Resident #1] had feces all over body and had feces all over bed rails. [Resident #1] was asleep at this time. This nurse [LVN A] and CNA [unknown] gave [Resident #1] a bed bath at this time. [Resident #1] was cleaned up, nails cleaned, and clothes changed. [Resident #1] had also pulled urostomy bag off; this nurse [LVN A] placed new bag. This nurse spoke to family and family states they understand she is not the only resident in facility, and they know this is what she has been doing lately [lately]. Family asked if they could place a complaint. This [LVN A] nurse notified .ADON and was given a complain sheet for family to fill out. Family filled out sheet and returned to this nurse [LVN A] who turned it into ADON. Family apologized and stated they were not sure why [Resident #1] continues to play in feces. Family educated.Record review of Resident #1's POC Response History Task: Toileting Hygiene revealed Resident #1 received toileting hygiene on 5/10/2026 at 4:16am. The POC Response History Task: bowel and bladder elimination revealed on 5/10/2025 at 4:18am Resident #1 had a large BM [bowel movement]. There were no documented Resident #1 refusals for either task for this date. There were no further task documentations that showed Resident #1 had been provided toileting hygiene after 4:18am and before 7:00am on 5/10/2026.Record review of Resident #1's progress notes for dates 5/09/2026-5/10/2026 did not reveal any documentation that stated resident had refused to be changed or refused toileting hygiene care prior to 7:00am on 5/10/2026.During an interview on 5/12/2026 at 10:33am, CNA E stated he had worked on 5/10/2026 day shift. He stated he entered Resident #1's room at approximately 7:15am to help CNA F. He stated when he entered the room, he saw Resident #1 had poop pasted on her. He stated family was in the room with CNA F because they had found Resident #1 in that state. He stated he felt Resident #1 had been laying in BM for a while because the feces appeared dry. He stated Resident #1 was given a bed bath by CNA F and LVN A in order to remove the feces from Resident #1. He stated the night CNAs were CNA G and CNA H. He stated the oncoming CNAs and off going CNAs should be rounding together and checking their assigned residents but that did not always happen. He stated he did not know if CNA F had checked Resident #1 before 7:15am. He stated the night CNAs usually conduct their last rounds at approximately 5:30AM but was not sure what time CNA G or CNA H had done their last night rounds. He stated he did not see skin breakdown or any redness on Resident #1's buttocks. He stated he had been trained to check on residents every two hours and more frequently on residents who may have behaviors. He stated residents being left in that manner was not okay and that is why they needed to do end of shift rounds with the oncoming staff, so things like this don't happen.During an interview on 5/12/2026 at 12:09pm, CNA F stated she had been assigned to care for Resident #1 on 5/10/2026 day shift. She stated when she arrived on shift at 6:00am she did lay eyes on Resident #1, but she was ensuring Resident #1 was in bed and that she was okay. She stated she did not check her brief at that time she just made sure Resident #1 was breathing and was safe. She stated that morning [5/10/2026] it was approximately 7:00am when Resident #1's family member told her Resident #1 had poop dried up on her. She stated she and LVN A went into the room to clean Resident #1. She stated it did appear Resident #1 had been laying in feces for a while because the feces was stuck and dried on the bed handrails. She stated during the shift change report, CNA G and CNA H had not mentioned that Resident #1 had refused to be cleaned up and had a current BM. She stated she felt that they should have checked on Resident #1 more often but during shift change, they only check to ensure residents are breathing and alive. She stated she did not believe the night shift staff had checked on Resident #1 as they should have before leaving the shift because between 6am to 7am the feces would not have been that dried. She stated she was not sure when nightshift would have done their last rounds, but they had to scrub the feces off Resident #1 during her bed bath. She stated residents with behaviors should be checked on for often than every two hours but sometimes they get busy assisting other residents and the two hours goes by quickly.During an interview on 5/12/2026 at 12:19pm, CNA H stated she had worked the night of 5/9/2026 to 5/10/2026 in the morning. She stated when they arrive on shifts all the residents are checked on and any needs are addressed such as changing, bathing, or getting them settled in bed for sleep. She stated rounds are done every two hours or more frequently if needed. She stated that morning [5/10/2026] she had done her last rounds at approximately 5am. She stated they had changed Resident #1 early in the shift and she had cleaned her hands because they had feces on them but after that CNA G did rounds on that side of the hall. She stated at 5am she did her last rounds and asked CNA G if she had checked on Resident #1 and CNA G told her she already had. CNA H stated she did not inquire further about Resident #1 because she took CNA G's word for it and left Resident #1 alone. She stated she asked CNA G about Resident #1 at approximately 5:30am but was not sure what time CNA G had actually rounded on Resident #1 or if she had needed any form of incontinence care. She stated when she returned for her next shift that night, she had been told Resident #1 had been found with dried feces on her and when she asked CNA G, CNA G told her don't worry I got you (the speaker has a situation completely under control and will take care of the problem on your behalf). CNA H stated she didn't know why CNA G was saying that, but she was upset that Resident #1 had been found that way and she did not want to get in trouble for something that was not her fault.Attempted interviews on 5/12/2026 with CNA G at 12:03pm, 12:08pm and 1:00pm, were unsuccessful. CNA G did not return any calls or messages. During an interview on 5/12/2026 at 2:00pm, LVN A stated she had been working on 5/10/2026 day shift. She stated she had been in the dining room helping with breakfast when CNA F told her Resident #1's family member wanted to speak to her. She stated she went to speak to Resident #1's family member and he was upset that Resident #1 had feces on her that was hard, so she had to receive a bed bath. She stated Resident #1 does have a behavior of grabbing her BM and smearing it on herself that requires her to be cleaned often. She stated she offered a complaint form to the family, and she returned the filled form to the ADON. She stated she did speak to the CNAs on that shift and educated on ensuring residents were being checked on earlier. She stated even though the feces was hard she could not place blame on day shift or night shift. She stated they were able to soak the BM off of Resident #1. She stated rounds should be done when the CNAs first get on shift and she has asked them to look at the briefs and below the sheets to ensure residents are clean. During the observation of a video dated 5/11/2026 at 1:33pm, the video revealed Resident #1's family member entering Resident #1's room. The video revealed Resident #1 resting in bed with a black/gray cover pulled up to her chest, a blue fall mat on the floor and the bed in a low position. The family member stated so I just got to [Resident #1] as soon as I walked into the room it smells like pee. Looks like she has been sitting in pee for quite a while because the bedsheets are dry from urine. The video focuses on the large urine stain on the sheet Resident #1 is lying on top of. The urine stain appeared to be dry. In a second video dated 5/11/2026 at 1:35pm it revealed Resident #1's saying tengo mucho frio (I am very cold) and the family member replying I know you're cold. It looks like her sheets been having pee forever and it's super dry, the video showed Resident #1's family member pulling the blanket down to show Resident #1's clothes. The clothes mid- abdomen and above were a shade of white with small sea/ocean designs. From the mid abdomen down, a yellowish stain was visible on the same shirt. The family members pulled the shirt down to show the shirt appeared to be dry where the stain was visible.Record review of Resident #1's progress notes for date 5/11/2026 did not reveal any documentation that stated resident had refused to be changed or refused hygiene care prior to 3:30pm on 5/11/2026.Record review of Resident #1's POC Response History Task: Toileting Hygiene and bowel and bladder elimination for 5/11/2026 did not reveal Resident #1 had received toileting hygiene or bowel and bladder elimination and there were no documented Resident #1 refusals of hygiene care. During an interview on 5/11/2026 at 6:10pm with LVN C, she stated she had been the charge nurse for the day. She stated when she arrived at her shift on 5/11/2026 she had laid eyes on Resident #1 and did not see anything out of the ordinary. She stated around lunch time, CNA D had gone into Resident #1's room and she was clean and dry. LVN C stated, next thing I know [Resident #1's family member] told CNA D she wanted Resident #1 out of here. She stated she called ADON and explained the situation and she was told to notify the physician, hospice and to send her to the hospital if that was what the family wanted. She stated Resident #1 was asleep and calm. She stated Resident #1 had dementia and had played in her feces before. She stated Resident #1 often removed her urostomy bag and they would have to frequently replace the bag. LVN C stated she had not observed any open wounds or sores to Resident #1's buttocks.During an interview on 5/11/2026 at 8:19pm, Resident #1's family member, she stated she was aware Resident #1 had behaviors where she refused care at times, but she felt the facility had left Resident #1 in her own urine and feces long enough for it to dry to her clothes and to her sheets. She stated there were times she would visit and would find feces on her nails but today on 5/11/2026 she had come to visit and Resident #1 had been laying in dried urine and her nails were dirty. She stated she just couldn't do it anymore and had Resident #1 sent to the hospital for an evaluation and to have her transferred to a different facility. She stated all she had wanted was for Resident #1 to be changed every two hours as the staff was supposed to, but she felt they were not rounding every two hours. She stated the hospital had cleaned up Resident #1 and changed her sheets.During an observation on 5/11/2026 at 8:29pm, of Resident #1 there were no open wounds, skin breakdown, sores or drainage noted from Resident #1's coccyx, left and right buttocks. On 5/11/2026 at 8:30pm Resident #1 was not interviewable due to severe cognitive deficits.During an interview on 5/12/2026 at 3:34pm with CNA D, she stated she had worked 5/11/2026 day shift and was assigned Resident #1's room. She stated she had gone into Resident #1's room at approximately 7-7:30am and had changed Resident #1's clothes and bedding. She stated Resident #1 had a behavior of ripping off her urostomy bag and often had urine leaking due to it being pulled on. She stated she checked on Resident #1 again at approximately 2pm before she went to her lunch break and Resident #1 was asleep and dry. She stated CNA I had passed out lunch trays and had gone into Resident #1's room at around 12:00pm. She stated rounds are done every two hours but on 5/11/2026 she had only rounded at 7:30am and 2:00pm. She stated between 7:30am to 2:00pm she was unable to go into the room as she was providing showers to other Residents. She stated she did not know if her partner went into Resident #1's room before 12:00pm but she knew CNA I had attempted to feed Resident #1 lunch. She stated when she came back from lunch Resident #1 was gone and had been told Resident #1's bed was wet with urine. She stated she asked CNA I if she had seen urine on the bed and CNA I had denied seeing wet urine on the bed. She stated a potential negative outcome of not providing hygiene care for Residents could be skin breakdown, new wounds or infection. She stated she was unable to see Resident #1's bed before she left the facility to see what had been missed.During an interview on 5/12/2026 at 3:48pm, CNA I stated she had worked 5/11/2026 day shift. She stated someone in Resident #1's room had pushed the call light, and she went into the room. She stated Resident #1's family member told her Resident #1 wasn't being herself and she had poop on her. She stated she did not see any poop, but she did see a yellow ring of urine on her bedsheet. She stated she could not tell if it was actively wet or dry, but she could see the urine ring. She stated Resident #1 was not assigned to her and had not rounded on her every two hours. She stated she remembered Resident #1's family member had called after 2pm because CNA D had just gone to lunch. She stated she did go into Resident #1's room at around 12pm for lunch and at that time she seemed okay but had not checked to see if she was wet, she only attempted to feed her lunch. She stated CNA D and her (CNA I) do communicate if they need them to do their rounds for them, but nothing had been communicated to her that day. She stated call lights are answered by everyone and that is why she had answered Resident #1's call light. She stated a potential negative outcome of not changing residents every two hours could be skin breakdown, wounds and diminished quality of care.During an interview on 5/12/2026 at 4:52pm, the ADON, she stated staff are trained to round every two hours. She stated residents who have behaviors such as Resident #1's should be rounded on more frequently. She stated Resident #1 did have a history of refusing care and they had been working with hospice on a plan to encourage Resident #1 to allow staff to provide the care, but she often still refused. She stated a potential negative outcome of staff not rounding every two hours could be skin breakdown, not meeting expectations, and resident needs not being met. She stated it is the residents' right to refuse care but if it became a habit or behavior, they needed to discuss a care plan that would address the new concerns. She stated staff cannot force the residents to receive care, but they should be encouraged and notifying family if the care is not able to be completed.During an interview on 5/12/2026 at 5:01pm, the ADM and RDO, the RDO stated they did not currently have a DON and the ADM's first day was 5/11/2026. The RDO stated staff were trained to round on residents every two hours and training is done upon hire and with annual competencies. She stated rounding involved checking on residents, making sure they are comfortable, ensuring they are not soiled, checking to see if they have fresh water and to assess each resident's well-being. The ADM stated rounding's at the end and beginning of shifts should be done together by the off going CNA and oncoming CNA to assess all the residents and provide care together if needed before the ongoing person left, that way it would ensure all residents were clean and comfortable. The RDO stated they would be monitoring POC's and ensuring all the tasks are being done and ADON would be doing spot checks as well. The ADM stated the potential negative outcome of not providing rounding every two hours could be falls, new wounds and poor quality of care. Record review of facility policy titled Activities of Daily Living (ALDs), Supporting last revised March 2018 revealed; Residents will [be] provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene, b. mobility, c. elimination (toileting), d. dining, e. communication.4. if a resident with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or a different time, or having another staff member speak with the resident may be appropriate.

Based on observation and interview the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 7 residents (Residents #1, #2, #3, #4, #5) and 1 of 1 staff (LVN A) reviewed for infection control. LVN A failed to sanitize hands between residents during medication administration for Residents #1, # 2, #3, #4, and #5 on 4/30/26.This failure could place residents at risk for spread of infection and cross contamination. Findings included:During an observation of medication pass on 4/30/26 at 9:00 PM, LVN A prepared medications for Resident #1 and administered medications. LVN A did not sanitize her hands before or after medication administration. During an observation of medication pass on 4/30/26 at 9:13 PM, LVN A prepared medications for Resident #2 and administered medications. LVN A did not sanitize her hands before or after medication administration. During an observation of medication pass on 4/30/26 at 9:18 PM, LVN A prepared medications for Resident #3 and administered medications. LVN A did not sanitize her hands before or after medication administration. During an observation of medication pass on 4/30/26 at 9:22 PM, LVN A prepared medications for Resident #4 and administered oral pill medications then LVN A administered one drop of eye drop medication in each eye. LVN held Resident #4's top eye lids open during the administration with her bare hand. LVN A did not sanitize her hands before or after medication administration nor did she wear gloves. During an observation of medication pass on 4/30/26 at 9:29 PM, LVN A prepared crushed medications mixed in jelly for Resident #5 and administered medications into the resident's mouth with a wooden spoon. LVN A did not sanitize her hands before or after medication administration. During an interview on 4/30/26 at 9:57 PM LVN A stated she was the charge nurse on Station 1. She stated if she remembered she would sanitize her hands between medication passes of residents. She stated she did not sanitize her hands every time between each resident because she forgot to do it. She stated she was trained to sanitize her hands between each resident even if she did not have any physical contact with them. LVN A stated she only sanitized between two of the residents because she remembered to do it but then she forgot again. She stated it was typical of her to forget to sanitize her hands during medication pass. LVN A stated she was not sure of the policy requirements for passing medications. She stated she was probably supposed to wear gloves when she administered eye drops, but she did not sanitize before or after she administered the eye drops on Resident #4 during medication pass. She stated she also gave Resident #5 their medication without sanitizing her hands after she gave Resident #4 their eyedrops. LVN stated this was concerning because the residents were fragile and it should not have happened that way. LVN A stated she was aware that not sanitizing between residents caused a risk of cross contamination and she could spread germs to residents and get them sick.During an interview on 5/1/26 at 2:50 PM, the DON stated the policy for hand hygiene during medication pass was that staff were expected to sanitize before and after passing medications to each resident. The DON stated she excepted staff to do hand hygiene and wear gloves when administering eye drops. She stated she was not aware a staff was not doing hand hygiene when administering eye drops and between medication passes. The DON stated staff were trained in hand washing and infection control during orientation training prior to training on the floor with residents. She stated she was responsible for ensuring staff completed hand hygiene and wore proper personal protective equipment during medication administration. She stated she expected staff to follow medication pass rights and chart in real time. She stated she expected staff to wear gloves and complete hand hygiene during med pass. The DON stated a potential negative outcome was that staff could spread infection to residents. She stated staff had been in-serviced on Enhanced Barrier Precautions as well.Record review of the facility's policy titled, Policies and Practices - Infection Control, revised October 2018, revealed in part: Policy Statement This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation2. The objectives of our infection control policies and practices are to:a. Prevent, detect, investigate, and control infections in the facility;b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public;c. Establish guidelines for implementing Isolation Precautions, including Standard and Transmission-Based Precautions;d. Establish guidelines for the availability and accessibility of supplies and equipment necessary for Standard and Transmission-Based Precautions;e. Maintain records of incidents and corrective actions related to infections; andf. Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment.Record review of the facility's policy titled, Handwashing/Hand Hygiene, revised October 2023, revealed in part: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Policy Interpretation and Implementation Administrative Practices to Promote Hand Hygiene1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Indications for Hand Hygiene1. Hand hygiene is indicated:a. immediately before touching a resident;b. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device);c. after contact with blood, body fluids) or contaminated surfaces;d. after touching a resident;e. after touching the resident's environment;f. before moving from work on a soiled body site to a clean body site on the same resident; andg. immediately after glove removal.Record Review of the facility provided policy, Administering Medications, revised April 2006, revealed in part: Policy Statement: Medications will be administered in a timely manner and as prescribed by the resident's Attending Physician or the facility's Medical Director.11. Established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) must be followed during the administration of medications.

Based on interview, observation, and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of all medications to meet the needs of the residents and establishes a system of records of receipt and disposition of all drugs in sufficient detail to enable an accurate reconciliation for 1 of 1 medication pass reviewed for pharmaceutical services in that:1. LVN A failed to document medications given on the EMAR immediately after administration to each resident during the nighttime medication administration on 4/30/26.2. LVN A failed to use the EMAR when she administered medications to residents during the nighttime medication administration on 4/30/26 and instead used a handwritten log as reference.These failures could place residents at risk of having their medications diverted and/or receiving the incorrect dosage.Findings included: Record review of LVN A's handwritten medication log, undated, revealed each resident's name and room number, and an abbreviated medication name was listed on the document. The handwritten medication log did not reveal the physician, time, dosage amount of each medication to be given. Additionally, some of the medication names were crossed out in black ink. During an interview and observation on 4/30/26 at 8:33 PM, LVN A stated she was responsible for the Station 1 medication cart. A handwritten medication log that contained resident's names, room numbers, and abbreviated medication names was observed sitting on top of the medication cart. LVNA stated she wrote medications for residents that she needed to give on a handwritten piece of paper because she did not have access to the EMAR on the tablets that were on the medication carts.During an observation on 4/30/26 from 9:00 PM to 9:47 PM, LVN A passed out medications to residents during the nighttime medication pass. LVN A was observed referring to and comparing the handwritten medication log to the label on each resident's medication blister packs. LVN A popped the pills in a cup and then gave them to each resident. LVN A then returned to the medication cart and crossed out the name of the medications on her handwritten log that she gave to each resident. During an interview on 4/30/26 at 9:57 PM LVN A stated she was the charge nurse in Station 1 hall. LVN A stated to prepare for passing medications, she went to the desktop computer and looked up each resident's EMAR in their computer system called Point Click Care and wrote down all the medications she was going to pass to each resident on a piece of paper. She stated she was unable to access the EMAR from the tablet that was on the medication cart that staff were supposed to use when passing medications. She stated she had access to the EMAR on the desktop computer but could not log in on the tablets on the medication carts. LVN A stated after she wrote everything down, she looked at her handwritten medication log and looked for a resident's medication on the medication cart; then she compared them again to her handwritten medication log and popped the medications in the cup. She stated then she gave the medications to the resident. She stated she made sure the residents took the medications and gave them water. LVN A stated she then marked a line through the medications given on her handwritten log. LVN A stated she was not sure of the policy requirements for passing and documenting medications. She stated she had not been told anything about writing her own medication pass log, however the DON most likely did not know she was doing that. She stated she charted the medications she gave to the residents on the desktop computer after she was done passing out all the medications. She stated she had never thought about it being risky to do it that way, but she still did not see any risk in her doing it that way. She stated she was responsible for all medications on that cart. LVN A stated she received training and in-services on medication pass and she was supposed to chart the medications in the EMAR when she gave them to the residents. LVN A stated a potential negative outcome was that the wrong medication could be given or a medication could be missed and they could have a bad reaction to the medications. She stated she told someone that she did not have access to EMAR on the Station 1 medication cart but could not remember who or when she told them. During an interview on 4/30/26 at 2:50 PM, the DON stated when passing out medications staff were to open the resident's EMAR and check the name, medication, dose, amount, and allergies before administering medications to residents. The DON stated staff were to explain the medications being given to the residents and document the medications that were being given in the EMAR as they were popped in the cup, then administer the medication, then return to the EMAR and save or make changes of refused if needed. She stated she was not aware staff wrote and used handwritten medication pass logs to pass medications. She stated she was not aware staff documented in residents' EMAR's after they completed the medication pass for all residents. She stated she was not aware of any staff who could not access the EMAR on the tablet on the medication carts. She stated the system in place to ensure medication pass documentation was timely and accurate was for staff to use the tablet that was attached to the medication carts. She stated she expected staff to use the tablets to document medications given to residents in real time on the tablets. The DON stated staff were not supposed to hand write their own medication pass logs and then use them to administer medications. The DON stated staff were not supposed to post-document medications and were expected to document as they were being administered. The DON stated herself and the ADON were responsible to ensure medication pass was documented timely, properly, and accurately in the EMAR. She stated staff had not been trained in documenting medications during the medication pass process since she started working here. She stated staff had been trained to use the EMAR when passing medications. She expected staff to use the EMAR and document as they were passing meds to residents. She stated a potential negative outcome was that medication errors could happen, dosages could be wrong, and it was not safe.Record Review of the facility provided policy, Administering Medications, revised April 2006, revealed in part: Policy Statement: Medications will be administered in a timely manner and as prescribed by the resident's Attending Physician or the facility's Medical Director.Policy Interpretation and Implementation8. The individual administering the medication must ensure that the right medication; right dosage, right time and right method of administration are verified (e.g., review of drug label, physician's order, etc.) before the medication is administered.9. The individual administering the medication must initial the resident's MAR on the appropriate line and date for that specific day before administering the next resident's medication.13. When medications are administered, the individual administering the medication must record in the resident's medical record:a. The date and time the medication was administered;b. The dosage;c. The route of administration;d. The injection site (if applicable);e. Any complaints or symptoms for which the drug was administered;f. Any results achieved and the time such results were observed; andg. The signature and title of the person administering the drug.Record Review of the facility provided policy, Charting and Documentation, revised July 2017, revealed in part: Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation2. The following information is to be documented in the resident medical record:a. Objective observations;b. Medications administered;c. Treatments or services performed;3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation and interview the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 1 medication carts (Station 1 Cart) observed in the facility. The facility failed to ensure the Station 1 medication cart was secured when unattended on 4/30/26.This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm, drug overdose, or drug diversion. Findings included: During an observation on 4/30/26 at 8:14 PM the Station 1 medication cart was observed in the station 1 hallway with the lock popped out unattended and without a staff present. LVN A was observed coming out of a resident room and approaching the medication cart.During an observation and interview on 4/30/26 at 8:33 PM the Station 1 medication cart was observed in Station 1 hallway with the lock popped out unattended and without a staff present. LVN A was observed in Resident room [ROOM NUMBER]-B helping another staff transfer a resident into their bed with a mechanical lift. As the Surveyor was waiting by the Station 1 medication cart, Resident #2 and their family approached the medication cart and waited next to it. LVN A then exited Resident room [ROOM NUMBER]-B with the mechanical lift and proceeded to approach the medication cart. She then moved the medication cart, and Resident #2 and their family member went on into Resident #2's bedroom. LVN A parked the lift at the end of the Station 1 hallway and then approached the medication cart. LVN A stated she was the charge nurse and was assigned to the Station 1 medication cart. The surveyor pulled on all the drawers and all of drawers opened. The drawer that contained the narcotic medications opened however the lock box was secure. Various cards and bottles of medications and medical supplies were observed in the drawers of the medication cart that opened. LVN A stated she was in the process of passing out medications to residents but went to help transfer a resident to their bed.During an interview on 4/30/26 at 9:57 PM LVN A stated she was the charge nurse during the shift. She stated she was responsible for the Station 1 medication cart. She stated she was trained and had been in-serviced that medication carts were supposed to be always locked, the narcotic box was supposed to be locked, and the keys were to always be with her. She stated she was in the middle of passing out medications when she went to help another staff transfer a resident with the mechanical lift. She stated she forgot to lock the medication cart and should have locked the cart, and she took responsibility for that. She stated she was responsible for all medications on that cart and could get into trouble for not locking it. She stated a potential negative outcome was that confused residents could get medications and take them, someone could steal the medications, or there could be drug diversion. She stated residents would go without their medications if they were lost or stolen, and this could affect residents financially if they had to pay for the missing medications. During an interview on 5/1/26 at 2:50 PM, the DON stated the policy was that medication carts should be locked anytime they were unattended and that there were frequent rounds completed by staff to ensure carts were locked. The DON stated she was not aware night staff left medication carts unlocked and unattended. She stated that she and the ADM were responsible for ensuring medication carts were locked when unattended. The DON stated in-services had been provided to staff to ensure they locked the medication carts. She stated she expected staff to lock the carts for safety when they were left unattended. The DON stated a potential negative outcome was that especially confused residents, visitors, and staff could take medications that were not theirs and it was a safety issue as there could be negative interactions with their other medications.Record Review of the facility provided policy, Storage of Medications, revised November 2020, revealed in part: Policy Heading: The facility stores all drugs and biologicals in a safe, secure, and orderly manner.6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, [NAME], and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.Record Review of the facility provided policy, Administering Medications, revised April 2019, revealed in part: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.

Based on interviews, observation, and record review, the facility failed to ensure all residents were treated with respect and dignity for 1 of 7 residents (Resident # 1) reviewed for dignity.LVN A failed to treat Resident #1 with respect and dignity when she told Resident #1 to go to his room or to go outside and smoke when he asked for medications and when he was talking to staff and visitors in the dining room. This failure placed residents at risk of emotional distress, embarrassment, and lower self-esteem. Findings included:Record review of Resident #1's face sheet dated 4/30/26, revealed Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Acute respiratory failure with hypoxia (lack of oxygen in the bloodstream), chronic pain due to trauma, major depressive disorder (mental illness), chronic obstructive pulmonary disorder (severe breathing difficulties), anoxic brain damage (damage to the brain due to loss of oxygen), other seizures (uncontrolled convulsions and loss of consciousness), dysphagia (difficulty swallowing), muscle weakness, muscle spasm (involuntary contractions of the muscle), cognitive communication deficit (trouble organizing thoughts, managing conversations, or understanding information), dysarthria (speech disorder caused by brain damage), anarthria (severe speech disorder resulting in complete inability to produce speech, and myoclonus (involuntary jerking muscle spasms caused by nervous system disorder).Record review of Resident #1's annual MDS Assessment, dated 3/01/2026 revealed a BIMS Score of 13 which indicated the resident's cognition was intact. Record review of Grievance Log, dated April 2026, revealed Resident #1 submitted a grievance on 4/12/26, night nurse treats him like a kid and gives his meds last [name of LVN A]. ADM spoke with nurse and she stated she just passes meds and resident demands his meds all the time. Explained to nurse that he may want his at a certain time and to try and give his first sometimes. Nursing administration will monitor closely and talk with resident at random times. signed by Former ADM During an interview on 4/30/26 at 10:00 AM, the Former ADM stated Resident #1 received his medications from the nurse (LVN A) because he wanted his medications given to him at a certain time. The Former ADM stated since then Resident #1 said he always gets his medication last.During an interview on 4/30/26 at 11:00 AM, Resident #1 stated last night (4/28/26) LVN A parked her cart long-ways in the Station 1 hall when she passed out medications, and he could not get past it in his wheelchair. He stated he asked her to move it, and she got mad and told him to go outside and smoke. He stated he told LVN A he was going to smoke but still needed to get by to go back to his room after he was done. He stated last night (4/28/26) in the dining room, he stopped and talked to a CNA eating chicken with their family member in the common dining room and LVN A approached all three of them and told him he needed to leave them alone, so he left the area. Resident #1 stated LVN A zig zagged rooms when passing out medication and would skip his room and gave his medication last during the medication pass between 8:00 PM and 10:00 PM. He stated when he had approached her at the nurse's station desk to ask for his medication, and she told him to go to his room or go to smoke. Resident #1 stated when he asked for things, LVN A often told him to wait and go smoke, and she would have it ready when he came back from smoking. Resident #1 stated he reported this to the DON, and she told him she would talk to LVN A and straighten it out. He said he also told the Former ADM who told him he would talk to LVN A. Resident #1 stated he believed LVN A treated him like this because one time he called her a name. Resident #1 stated he got upset when LVN A was rude to him and felt like she treated him like a child. During an interview on 4/30/26 at 2:58 PM, Resident #6 stated she felt LVN A did not like Resident #1. Resident #6 stated Resident #1 had asked LVN A for his medications when it was time for him to receive them, but LVN A told Resident #1 he had to wait and she also told Resident #1 he had to wait when he asked for his shower. Resident #6 stated she felt LVN A had a grudge against Resident #1 because he called her a curse name one time. Resident #6 stated she felt Resident #1 did not irritate LVN A when he asked for his medications as he just simply asked for them because it was time. During an interview on 4/30/26 at 4:43 PM, the Former ADM stated Resident #1 believed LVN A passed his medications last on purpose, so he told LVN A to give his medications first sometimes. The Former ADM stated he had not been told Resident #1 had issues with being told to wait to take showers. The Former ADM stated LVN A told him Resident #1 demanded his medications when he wanted them. The former ADM stated he did not think LVN A was rude but there may have been concerns with her approach, as she was sometimes short in her responses, which could be considered rude.During an observation on 4/30/26 at 9:05 PM, LVN A was in the Station 1 hallway in the process of passing out medications to residents when Resident #1 approached his bedroom doorway and asked for his PRN pain medication. LVN A told Resident #1 she would look into it and told Resident #1 to go back into his room and watch television.During an interview on 4/30/26 at 9:57 PM LVN A stated she was the charge nurse on Station 1. She stated she parked the cart long ways in the hall instead of against the wall so she could see both sides of the hall in front of her because she was doing rounds at the same time. She stated Resident #1 was in and out of his room all night and she would move the cart and or he would go around it, but she realized this was his home and he should not have to move things to get around the facility and that the hallways should be kept free of clutter. She stated she told Resident #1 to go to his room when he came out of his room to ask for his medication so he could relax and wait on her so she could check to make sure his medication was due. She stated Resident #1 frustrated others sometimes, for example last night (4/29/26), a CNA was having dinner with their family member in the dining room. LVN A stated she saw Resident #1 talking to them in the dining room so she approached them and she told Resident #1 to move away from them and go to his room or go outside and smoke so they could eat. LVN A stated there was a breakroom for staff to eat in, but they were eating in the resident dining room since her family member was there, so she allowed them to sit in the dining room. She stated she now realized this was the resident's home and he had the right to talk to people in the dining room. LVN A stated the Former ADM told her to be more patient with Resident #1, but she was not told why she needed to be more patient with him. LVN A stated she was not told Resident #1 complained that she gave his medication last. LVN A stated Resident #1 sometimes refused to shower. LVN A stated she did not recall if Resident #1 called her a curse name in the past. During an interview on 4/30/26 at 9:57 PM CNA B stated she believed there was something going on back and forth between Resident #1 and LVN A. CNA B stated Resident #1 followed CNA A when she passed medications. CNA B stated LVN A had asked Resident #1 not to follow her and he told her he needed his medication. CNA B stated Resident #1 would quit following LVN A after he got his medication. CNA B stated Resident #1 went to the nurse's station around 11:30 PM to ask for his PRN pain medication and LVN A took it to him in his room.During an interview on 5/1/26 at 12:20 PM, the sister facility ADM stated Resident #1 approached her this morning and expressed some concerns about LVN A and that he felt LVN A treated him like a child. During an interview on 5/1/26 at 2:50 PM, the DON stated staff had been in-serviced on being mindful of tone and language and to be respectful of residents. The DON stated she was only aware that Resident #1 had previously complained that LVN A skipped him on the medication pass and gave his medications last. The DON stated she talked to LVN A who explained she was passing medications on a rotation and not purposely skipping Resident #1. The DON stated she instructed LVN A to make sure she went in order if that was what she was doing but not to skip him. The DON stated she was aware LVN A had told Resident #1 to go to his room before and she told LVN A to be more mindful of how she spoke to the resident. The DON stated sometimes going out of order when passing out medications could cause the staff confusion and that could be why the staff did not want to give medications out of order. She stated she was not aware of an incident when LVN A told Resident #1 to go to his room or go outside and smoke when she saw him talking to a staff and their family member that were eating in the dining room. She stated staff had been trained in how to treat residents with dignity. The DON stated the ADON, the DON, and the ADM were all responsible to ensure staff treated residents with respect and dignity. The DON stated sending Resident#1 to their room or to go smoke was not the appropriate way to redirect the resident. The DON stated it was not appropriate for staff to redirect a resident from talking to staff eating in the dining room, this was their home, staff could eat other places such as outside, in their car, or other areas designated for staff such as the breakroom if they did not want to be interrupted by residents. She stated she expected staff to treat residents with respect and dignity. The DON stated a potential negative outcome was that it could cause residents emotional distress and make them feel uncomfortable here and this could also have caused Resident #1 to feel isolated if he felt he must stay in his room.Record Review of the facility provided policy, Resident Rights, revised February 2021, revealed in part: Policy Statement Employees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and Implementation1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;c. be free from abuse, neglect, misappropriation of property, and exploitation;d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms;e. self-determination;f. communication with and access to people and services, both inside and outside the facility;Record Review of the facility provided policy, Administering Medications, revised April 2019, revealed in part: Policy Statement: Medications are administered in a safe and timely manner and as prescribed.Policy Interpretation and Implementation5. Medication administration times are determined by resident need and benefit, not staff convenience.Factors at are considered include:a. Enhancing optimal therapeutic effect of the medication;b. Preventing potential medication or food interactions; andc. Honoring resident choices and preferences, consistent with his or her care plan.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #41) reviewed for infection control. The facility failed to ensure Resident #41's room had clear signage regarding Enhanced Barrier Precautions (EBP). This failure could place residents at risk for cross contamination and infection. The findings included: Record review of the face sheet for Resident #41, dated 03/05/26 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: peripheral vascular disease (poor circulation), insomnia (sleep problems), and acute upper respiratory infection. Record review of the quarterly MDS assessment for Resident #41, dated 12/02/25 revealed Resident #41 had a BIMS score of 15 which indicates his cognition was intact. Record review of the order summary report for Resident #41, dated 03/05/26, revealed an order: Enhanced Barrier Precautions: daily wound care every shift with a start date of 01/19/26. Record review of the care plan for Resident #41, last care plan review completed 03/03/26 revealed: Focus: Enhanced Barrier Precautions Will be used due to indwelling and non-intact skin, or when coming in contact with blood, body fluids, mucous membranes or non-intact skin. With an initiation date of 01/19/2026. During the initial tour observations on 03/03/26 at 10:10 AM, Resident #41's room was observed with no PPE box outside the room and no signage on the door regarding EBP. During an observation on 03/03/26 at 11:37 AM, Resident #41's room was observed with no signage on the door regarding EBP. During an interview on 03/03/26 at 11:38 AM, Resident #41 stated sometimes staff wore a gown when providing care to him and sometimes they did not wear a gown. Resident #41 stated he did not know why the staff wore a gown for his care at times and not at other times. During an interview on 03/05/26 at 10:18 AM, LVN B stated the EBP signs were supposed to be taped on the doors to the residents' rooms. LVN B stated sometimes the signs would fall off. LVN B stated the ADM would usually go around the facility to ensure the EBP signs were on the doors they needed to be on. LVN B stated everyone was responsible for ensuring the residents who were on EBP had a sign on their door. LVN B stated a potential negative outcome to the residents was a risk for infection going in their room with no PPE on. During an interview on 03/05/26 at 10:23 AM, the DON stated she was responsible for ensuring EBP signs were replaced when they fell off of a resident's door. The DON stated she did not know about the prior staff training on EBP due to her only being in the DON role for 2 weeks. The DON stated she did not know why Resident #41 did not have a sign for EBP on his door. The DON stated a potential negative outcome to the residents was a risk for infection. During an interview on 03/05/26 at 2:13 PM, the ADM stated he expected residents who were on EBP to have a sign on their door. The ADM stated he walked around the facility every morning and would check for the EBP signs on the doors and would replace them if necessary. The ADM stated the signs would fall off easily due to being taped onto the door. The ADM stated all of the staff were responsible for ensuring the EBP signs were put back on the doors when they fell off. The ADM stated an in-service for EBP was done recently at the facility. The ADM stated a potential negative outcome was the spread of infection. Record review of the facility policy title, Enhanced Barrier Precautions, dated August 2022 reflected the following: Policy StatementEnhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents.Policy Interpretation and Implementation1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. Record review of the CDC website regarding EBP guidelines, https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html reflected the following: -Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE.-For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves.

Based on record reviews and interviews, the facility failed to provide or obtain laboratory services only when ordered by a physician for 1 of 24 residents (Resident #8) reviewed for laboratory results in that:The facility failed to ensure Resident #8's Dilantin (Phenytoin) blood level was drawn monthly on the 21st of each month, as ordered by the physician, in January 2026 or February 2026.The facility failed to ensure Resident #8's Keppra (Levetiracetam) blood level was drawn monthly on the 21st of each month, as ordered by the physician, in January 2026 or February 2026. This failure could place residents with laboratory work orders at risk of not having their medical needs met. Findings include: Resident #8 Record review of Resident #8's electronic face sheet dated 03/03/2026 revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include the following: Epilepsy, unspecified, not intractable without status epilepticus (brain disorder characterized by recurrent episodes of abnormally increased neuronal discharge, leading to transient sensory, motor, or psychic dysfunction), unspecified intracranial injury with loss of consciousness status unknown, initial encounter (Traumatic brain injury), and other seizures. Record review of Resident #8's Order Summary Report dated 03/03/2026 revealed, under Laboratory, Order Summaries stating, Monthly Dilantin Level one time a day starting on the 21st and ending on the 21st every month related to UNSPECIFIED CONVULSIONS., Monthly Keppra Level one time a day starting on the 21st and ending on the 21st every month related to UNSPECIFIED CONVULSIONS. Record review of the clinical record for Resident #8's laboratory record results revealed the following: There were no laboratory record results found for January 2026 or February 2026 for Resident #8. During an interview on 03/04/2026 at 04:00 PM the DON stated she was unable to locate laboratory results for Resident #8 for January 2026 or February 2026, completed by the facility. The DON stated she contacted the laboratory the facility used, and the laboratory results were not drawn for those months by the laboratory. The DON stated she did not know why the laboratory results were not drawn as she was not working at the facility at that time. During an interview on 03/05/2026 at 02:00 PM the DON stated she had worked at the facility as the DON since February 2025. The DON stated the ADON was responsible for ensuring laboratory orders were completed for each resident that had monthly laboratory orders. The DON stated the facility was working on a system for ensuring laboratory results were completed when ordered. The DON stated she received notifications via email when a laboratory order was scheduled. The DON stated she did not know if the ADON received notification of Resident #8's scheduled laboratory orders from January and February 2026 since she was not working at the facility at that time. The DON stated she was not aware the laboratory orders were not completed for Resident #8 for January and February 2026. The DON stated it was her expectation that laboratory orders were completed according to the physician's orders. The DON stated all nursing staff were trained on reviewing physician orders. The DON stated she planned to review all laboratory orders for residents in the future to ensure they were completed. The DON stated it was important to ensure laboratory orders were completed to monitor medication levels so changes could be made, and to prevent incidents from occurring such as seizures. During an interview on 03/05/2026 at 2:15 PM the ADON stated she had worked at the facility since November 2025. The ADON stated it was the previous DON's responsibility to ensure laboratory orders were completed. The ADON stated she was never trained to complete laboratory orders or to ensure they were completed. The ADON stated the facility had a roster of residents with laboratory orders to track current laboratory orders. The ADON stated the facility was working on a new system to ensure laboratory orders were completed. The ADON stated she was not aware laboratory orders were missed for Resident #8 in January and February 2026. The ADON stated she did not receive training from the previous DON on reviewing laboratory orders and the process of ensuring they were completed. The ADON stated it was her expectation that laboratory orders were completed as ordered by the physician. The ADON stated if laboratory orders were missed, the facility could have missed something critical, and it was important to obtain a new laboratory order as soon as possible, if one was missed. During an interview on 03/05/2026 at 02:30 PM the ADM stated the DON and ADON were responsible for ensuring laboratory orders were completed as ordered by the physician. The ADM stated the facility went through a staffing change with the DON, and he was not sure why Resident #8 did not have laboratory results completed for January or February 2026. The ADM stated he did not know what system was in place to ensure laboratory orders were completed, but the facility was working on a new system to monitor it more closely. The ADM stated it was his expectation that every laboratory order was drawn per the physician orders. The ADM stated all nursing staff received training pertaining to following and reviewing physician orders. The ADM stated he was not aware the laboratory results were not completed for Resident #8 for January or February 2026. The ADM stated it was important for laboratory results to be drawn as ordered by the physician to ensure residents were monitored and to prevent injuries and incidents from occurring. Record Review of the facility's policy titled, Lab and Diagnostic Test Results - Clinical Protocol, revealed the following:Assessment and Recognition1. The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs.2. The staff will process test requisitions and arrange for tests.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly in a locked compartment for 1 of 2 nurse carts (Nurse Cart A) reviewed for medication storage. The facility failed to ensure Nurse Cart A was locked when not in use. This failure could place residents at risk of having access to unauthorized medications and lead to an increased risk for drug diversion and possible harm. The findings included: During an observation on 03/03/26 at 9:38 AM, Nurse Cart A was observed unlocked and unattended on Hall 2. No residents or staff were present by the nursing cart. During an observation on 03/03/26 at 12:15 PM, Nurse Cart A was observed unlocked and unattended on Hall 2. No residents or staff were present by the nursing cart. During an interview on 03/03/26 at 12:18 PM, LVN A stated she did not know why Nurse Cart A was unlocked in Hall 2. LVN A confirmed wound care supplies were available for use in Nurse Cart A by opening the cart. LVN A stated she had been trained on locking the medication and nursing carts when not in use but could not remember when the last training was. LVN A stated a potential negative outcome to the residents was a resident with dementia could get into the cart and get medications or bandages. During an interview on 03/05/26 at 10:23 AM, the DON stated she expected the nursing carts to be locked when not in use. The DON stated the charge nurse was responsible for ensuring the nursing carts were locked when not in use. The DON stated she did not know why Nurse Cart A was unlocked on Hall 2. The DON stated she did not know the last time the nursing staff was trained on locking the nursing carts when they were not in use. The DON stated a potential negative outcome to the residents was they could get into the different supplies in the nursing cart. During an interview on 03/05/26 at 2:13 PM, the ADM stated the nursing carts should be locked when they were not in use. The ADM stated the charge nurse or the medication aide was responsible for locking the medication cart or the nursing carts when they were not in use. The ADM stated the staff were trained on locking the carts when not in use but he could not remember exactly when. The ADM stated a potential negative outcome to the residents was they could get into the medications and it could be harmful to the residents. Record review of the facility policy titled, Storage of Medications with a revised date of November 2020 reflected the following: Policy headingThe facility stores all drugs and biologicals in a safe, secure, and orderly manner.Policy Interpretation and Implementation1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications.6. Compartments (including but not limited to.carts.) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents (Resident #1, Resident #2 and #3) reviewed for infection control.1. CNA A failed to change gloves when going from dirty to clean when providing incontinence care for Residents #1, #2, and #3. These failures could place residents at risk for cross contamination and infection. The findings include: Resident #1 Record review of the admission record for Resident #1, dated 09/05/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: cerebral palsy (a group of permanent movement disorders that affect brain-controlled muscle functions), schizoaffective disorder, bipolar type (mental health disorder) and anemia (not enough red blood cells to carry oxygen throughout the body). Record review of the quarterly MDS assessment for Resident #1, dated 08/27/25 revealed Resident #1 was always incontinent of bladder and bowels. Record review of the current care plan for Resident #1, last reviewed on 06/27/25, revealed there was a focus area: Bladder/Bowel Incontinence: I have bowel and bladder incontinence. During an observation on 09/05/25 at 11:30 AM, CNA A provided incontinence care and catheter care for Resident #1 with the help of CNA B. CNA A and CNA B washed their hands with soap and water and put on a clean pair of gloves. CNA A then unfastened the brief for Resident #1 and began cleaning his groin area with wipes. Resident #1 was turned on his side and CNA A removed the old brief. CNA A then wiped Resident #1's buttocks and placed a clean brief under Resident #1. CNA A secured the new brief and pulled up Resident #1's pants with the help of CNA B. CNA A then removed her gloves and used hand sanitizer to clean her hands. CNA A did not change her gloves and perform hand hygiene before going from dirty to clean during the procedure. Resident #2 Record review of the admission record for Resident #2, dated 09/05/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: atherosclerotic heart disease (thickening or hardening of the arteries) dysphagia (difficulty swallowing), and aphasia (a language disorder that makes it difficult to communicate). Record review of the quarterly MDS assessment for Resident #2, dated 08/17/25, revealed Resident #2 was always incontinent of bladder and bowels. Record review of the current care plan for Resident #2, last reviewed on 09/04/25, revealed there was a focus area: [Resident #2] has bladder incontinence r/t history of UTI (Urinary Tract Infection). During an observation on 09/05/25 at 11:00 AM, CNA A provided incontinence care for Resident #2 with the help of CNA B. CNA A and CNA B washed their hands with soap and water and put on clean gloves. CNA A then unfastened Resident #2's brief and cleansed his groin with wipes. Resident #2 was turned on his side and CNA A wiped his buttocks with wipes. CNA A then removed the dirty brief and placed a clean brief under Resident #2 without changing her gloves. CNA A then secured Resident #2's brief and pulled his pants up. CNA A then transferred Resident #2 to his wheelchair and removed her gloves. CNA A then used hand sanitizer to cleanse her hands. CNA A did not change her gloves and perform hand hygiene before going from dirty to clean during the procedure. Resident #3 Record review of the admission record for Resident #3, dated 09/05/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: cerebral palsy (a group of permanent movement disorders that affect brain-controlled muscle functions), strabismus (crossed eyes or squint), and mild intellectual disabilities. Record review of the comprehensive MDS assessment for Resident #3, dated 07/30/25, revealed Resident #3 was frequently incontinent of bladder and always incontinent of bowels. Record review of the current care plan for Resident #3, last reviewed on 09/04/25, revealed there was a focus area: [Resident #3] has bowel and bladder incontinence. During an observation on 09/05/25 at 11:45 AM, CNA A provided incontinence care for Resident #3 with the help of CNA B. CNA A and CNA B washed their hands with soap and water and put on clean gloves. CNA A pulled down Resident #3's shorts and then unfastened Resident #3's brief. CNA A then cleansed Resident #3's groin with wipes. CNA A then removed Resident #3's old brief and then wiped his buttocks with wipes. CNA A placed a clean brief under Resident #3. CNA A secured Resident #3's brief and pulled up Resident #3's shorts. CNA A then transferred Resident #3 to his wheelchair. CNA A then removed her gloves and used hand sanitizer to cleanse her hands. CNA A did not change her gloves and perform hand hygiene before going from dirty to clean during the procedure. During an interview on 09/05/25 at 11:53 AM, CNA A stated she had received training regarding changing her gloves and performing hand hygiene when going from dirty to clean during a procedure. CNA A stated she could not remember the last time she was trained for incontinence care and infection control. CNA A stated she did not change her gloves and perform hand hygiene when going from dirty to clean because she did not think about it. CNA A stated the residents had an increased risk for UTI's and germs. During an interview on 09/05/25 at 11:54 AM, the DON stated she expected the staff to change their gloves and perform hand hygiene when going from dirty to clean when providing care to a resident. The DON stated she did not remember when the last training was for incontinence care/infection control and stated the staff were scheduled to be trained that month regarding infection control. The DON stated CNA A usually did transport for the facility but would get pulled to the floor if a CNA called in. The DON stated a potential negative outcome to the residents was possible infections or UTI's. During an interview on 09/05/25 at 2:35 PM, the Admin stated she expected the staff to change their gloves when going from dirty to clean when providing care. The Admin stated CNA A probably was not paying attention or was nervous and that was why she forgot to change her gloves and perform hand hygiene when going from dirty to clean. The Admin stated CNA A was usually the van driver for the facility, but she was pulled to the floor because someone call in that day. The Admin stated CNA A was trained to change her gloves when going from dirty to clean. The Admin stated the residents had a potential negative outcome for spreading infection. Record review of the facility policy titled, Policies and Practices - Infection Control, with a revised date of October 2018 reflected the following: Policy Statement: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.

Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) and the Abuse Coordinator for 3 of 6 residents (Resident #1, #2, and #3) reviewed for abuse. A. The ADM failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC regarding Resident #1 being fed forcibly by CNA A on an unknown date. B. The ADM failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC regarding Resident #2 being transferred in a rough manner (chucked in the bed) by CNA A on an unknown date. C. The ADM failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC regarding Resident #3 being changed improperly by CNA B on an unknown date. These failures could place residents as risk for abuse and neglect. Findings included: Resident #1 Record Review of Resident #1's face sheet, dated 1/28/25, revealed a [AGE] year-old female that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss) and anxiety (increased worry). Record Review of Resident #1's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 00, indicating the resident was severely cognitively impaired. Section E revealed Resident #1 did not exhibit physical behavior (hitting, kicking, pushing, scratching, grabbing, and abusing) during the review period [E0200]. Section GG revealed Resident #1 was dependent on staff for all her eating needs [GG0130]. Section K revealed that Resident #1 had the following swallowing disorder: coughing or choking during meals [K0100.]. Record review of Resident #1's progress notes dated from 10/27/24- 1/28/25 did not reveal any information regarding choking or allegation of abuse between the dates of 1/01/25-1/28/25. Record review of Resident #1's care plan, dated 1/21/25, revealed a focused area, initiated on 12/13/23, Resident #1 had an ADL self-care performance deficit r/t dementia. The goal initiated on 12/13/23, was Resident #1 would maintain current level of function through the review date review date (02/06/24-01/21/25). The interventions initiated 12/13/23 included while eating Resident #1 would be fed for all meals. During an interview on 1/28/25 at 2:50 PM, Resident #1 was unable to answer any questions about the staff's feeding technique. She lay in bed and was nonverbal at the time of the attempted interview. Resident #2 Record Review of Resident #2's face sheet, dated 1/28/25, revealed a [AGE] year-old female that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss), pain in unspecified joint and anxiety (increased worry). Record Review of Resident #2's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 03, indicating the resident was severely cognitively impaired. Section GG revealed Resident #2 requires partial or moderate assistance when it comes to chair/bed to chair transfer. Record review of Resident #2's progress notes dated from 10/27/24- 1/28/25 did not reveal any information regarding improper transfer or allegation of abuse between the dates of 1/01/25-1/28/25. Record review of Resident #2's care plan, dated 6/14/24, revealed a focused area, initiated on 6/17/24, Resident #2 had an ADL self-care performance deficit r/t left hip and sacrum fracture. The goal initiated on 6/17/24, was Resident #2 would maintain current level of function through the review date review date (08/15/24-06/20/25). The interventions initiated 6/17/24 included Resident #2 required extensive assistance by 1 staff to move between surfaces. During an interview on 1/28/25 at 4:15 PM, Resident #2 stated she could not remember if staff had been rough with her. When asked about transfers, she said she could not remember anything. Resident #3 Record Review of Resident #3's face sheet, dated 1/28/25, revealed a [AGE] year-old female that was admitted to the facility on [DATE], with a diagnosis of Alzheimer's (memory loss) and anxiety (increased worry). Record Review of Resident #3's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 03, indicating the resident was severely cognitively impaired. Section E revealed Resident #1 did exhibit verbal behavior (threatening, screaming and cursing at others) during the review period [E0200]. Section GG revealed that Resident #3 requires substantial/maximal assistance regarding toileting hygiene [GG0130]. Section H revealed Resident #3 was always incontinent of bowel and urinary [H0300-0400]. Record review of Resident #3's progress notes dated from 10/27/24- 1/28/25 did not reveal any information regarding improper perineal care or allegation of abuse between the dates of 1/01/25-1/28/25. Record review of Resident #3's care plan, dated 3/08/24, revealed a focused area, initiated on 3/18/24, Resident #3 had bladder incontinence r/t Alzheimer's. The goal initiated on 3/18/24, was Resident #3 was at risk for septicemia (life threatening bacterial disease) will be minimized/prevented via prompt recognition and treatment of symptoms of UTI through review date (4/30/24-06/20/25). The interventions initiated 3/18/24 did not include instruction to staff on what to do regarding incontinence care. Record review of Resident #3's care plan, dated 3/08/24, revealed a focused area, initiated on 3/18/24, Resident #3 had an ADL Self Care performance deficit r/t Alzheimer's. The goal initiated on 3/18/24, was Resident #3 was to maintain current level of function in eating through the review date (4/30/24-06/20/25). The interventions initiated 3/18/24 stated Resident #3 was totally dependent on staff for toilet use. Record review of Resident #3's care plan, dated 3/08/24, revealed a focused area, initiated on 3/18/24, Resident #3 was resistive to care and would refuse to be changed r/t Alzheimer's. The goal initiated on 3/18/24, was Resident #3 would cooperate with care through review date (4/30/24-06/20/25). The interventions initiated 3/18/24 did not include if Resident #3 resisted with ADLs, negotiate a time so that the resident can participate in the decision making process. During an interview on 1/28/25 at 4:00 PM, Resident #3 did not provide any pertinent information related to the deficient practice. During an interview on 1/28/25 at 12:14 PM, Student C stated that she reported allegations of abuse when she was completing her clinical at the NF. She said she was not in a place where she could talk but could give the information later to the investigator. She said she did write a statement and reported the allegations of abuse to the ADON and the ADM that she had witnessed abuse and neglect at the facility. During an interview on 1/28/25 at 1:15 PM, CNA A stated she was unsure of the exact day and time but that Student C had alleged that she was doing something wrong. The CNA stated she did not do anything wrong. She stated that she was asked to write a statement and was addressed about the allegations immediately. She said she focused on providing care for her residents and would not abuse them. During an interview on 1/28/25 at 2:00 PM, the DON stated that she was unsure of the date and time but that Student C did not make a report of abuse to her. She said the report was made to the ADON. She said she was not clear on all the allegations, but it was her understanding that CNA A force-fed someone and threw someone on their bed. She said it was her understanding that an investigation was done, the facility cameras were watched, and none of the findings were valid. She stated she was unsure of which resident was force-fed but that she believed the resident who was thrown in bed was Resident #2. During an interview on 1/28/25 at 2:20 PM, the ADON stated she was unsure of the date and time, but Student C came to her at least three weeks ago with another employee (CNA D). She stated that she was told by CNA D that Student C needed to speak with her. The ADON stated that she was told by Student C that she (Student C) had an abuse case that she wanted to report. The ADON stated that the DON was off on that day, and as a result, she went to the ADM. She stated she did not want to take a statement regarding abuse by herself. She stated that in the presence of the ADM, CNA Student C stated that CNA A fed a resident with a spoon with too much food, making the resident choke. The ADON stated that Student C reported that CNA B performed perineal care incorrectly. The ADON stated that she could not fully remember what Student C alleged. She stated they had Student C write a statement, which was submitted to the ADM. The ADON stated it was her understanding that the information gathered was submitted to their corporate. She stated that it was told to her that what was told to her (the ADON) and what was on the statement were different. She stated they educated staff on what to do if residents are choking and how to conduct perineal care. She stated that they asked nurses if they had witnessed anything and that no one had reported anything. The ADON stated that after she, the DON, and the ADM got statements and consulted with corporate, it was concluded that Student C was a new CNA and everything was a first for Student C in the nursing home environment. The ADON stated she had been trained on the facility's abuse policy. She stated that failure to report allegations of abuse to HHSC could result in the nursing facility being shut down. She said abuse could continue if it is not reported correctly. She stated that the purpose of reporting allegations of abuse to HHSC was to ensure that residents are treated fairly and keep them free from abuse and that all allegations of abuse are investigated on a higher level. She stated she was unaware that the allegations had not been reported to HHSC. She stated she was unaware that the incident with Student C was supposed to be reported to HHSC. She stated that their system to monitor and ensure that the abuse policy was being followed was that all allegations of abuse should be reported to the abuse coordinator, the ADM. The ADON stated that in-services and education on expectations are conducted. She stated they are trained and train the staff to report anything that seems unjust and anything they would not want to their family members. She said the ADM and the DON will conduct the investigation and report the appropriate information to HHSC. She stated that she expected all allegations of abuse to be reported to the abuse coordinator (ADM), the abuse policy followed, and all staff educated accordingly. The ADON stated that the ADM and DON were responsible for reporting allegations of abuse to HHSC. She said she was unsure of the reason the allegations of abuse reported by Student C were not to HHSC. During an interview on 1/28/25 at 3:00 PM, the ADM stated he was unsure of the specific date and time, but Student C reported that she had concerns about how staff at the NF were taking care of the residents. He stated he had her write a statement. He stated that during their interview, Student C reported that a staff (CNA B) was rough with a resident, and the resident was screaming out. He said that he was told by Student C that another staff member (CNA A) had chucked another resident into bed. He said Student C stated that a staff (CNA A) overfed a resident and caused her to choke. The ADM said he took Student C's statement and sent it to his corporate staff. He stated he was instructed to conduct a 1:1 with both staff members, assess all residents, in-service all staff on customer care, and conduct safe surveys with residents. The ADM stated that Student C did not mention the term abuse or neglect. The ADM stated that he interpreted the student's statement that she had concerns but was not alleging abuse. He stated that he felt the student was bringing to his attention that the staff were rushing. He stated he would hope that his staff, when reporting serious incidents, would be specific and use the actual word abuse and neglect. She stated that she did not disclose the resident's names when Student C reported the incident. He stated that in the process of their investigation, they concluded that it was Resident #1 regarding the feeding incident, Resident #2 who was allegedly chucked on the bed, and Resident #3 involved in the perineal care. The ADM stated that because Student C did not provide names, he could not be 100 percent sure those were the residents involved. The ADM stated he did not report the allegations to HHSC because he did not perceive them as allegations of abuse but thought it was a concern in all three instances where staff may have been rushing and needed additional education. He stated that the purpose of reporting allegations to HHSC was to prevent abuse and to ensure that the resident's rights were being taken care of. The ADM stated that the potential negative outcome of not reporting all allegations of abuse to HHSC was that residents could endure abuse. He stated he was familiar with the facility's abuse policy and had been trained on the policy. He stated he was aware that he did not report the concerns to HHSC. He said their system for monitoring the implementation of the facility's abuse policy was to consult with corporate staff to see if they have enough evidence to report the allegation. He stated he had been trained to report all allegations of abuse to HHSC, and he expected all allegations of abuse. He stated he was responsible for reporting allegations of abuse to HHSC. During an interview on 1/28/25 at 3:30 PM, CNA D stated that she could not remember the date or the time, but a few weeks before her interview with the investigator, Student C came to her and stated she had observed abuse and neglect in the facility. She stated that she stopped Student C before she could report anything to her and explained to her that she could not take that type of report. She stated she took her to the Administrator's office. She stated they knocked, and he did not answer. CNA D stated she took Student C to the ADON. She stated that after that, she did not know what had happened with the abuse reporting process. During an interview on 1/28/25 at 3:40 PM, the DON stated that she had been trained on the facility's abuse policy and was familiar with it. She said she had been trained that all allegations of abuse had to be reported to HHSC. She said the purpose of reporting to HHSC was to protect residents from abuse while the investigations were being conducted. She said the potential negative outcome for the resident is that abuse can continue if not appropriately addressed. She said she was aware that the allegations from Student C were not reported to HHSC, but it was not reported because there were no findings that substantiated what Student C reported. The DON said she expected all allegations of abuse to be reported to HHSC. She said that she and the ADM were responsible for reporting allegations of HHSC. During an interview on 1/29/25 at 10:06 AM, CNA B stated she did not remember the exact date and time but had been asked to change Resident #3 with the assistance of student aides. She said that after she changed Resident #3, management asked her to write a statement because it was alleged that she was rough with Resident #3. CNA B told the students that Resident #3 was sensitive. She said that while changing Resident #3, she forgot that Resident #3 needed cream and had intended to tell the night shift to put cream on her. CNA B stated that one of the students (name unknown to her) went and retrieved the cream. She said, Thank you, and put the cream on her. She said she was unaware of any issues or concerns from the student aides at the time of the incident. She said she was given a warning about the incident. During an interview on 1/29/25 at 10:12 AM, the Regional Clinical director stated she received an email from the ADM (the email date was not disclosed during the interview). She stated that the email from the ADM stated that he (the ADM) had a grievance from one of the CNA students (she did not disclose which CNA student by name). She said she read Student C's statement that was attached to the email and advised the ADM to investigate, in-service, and conduct safe surveys. She stated that after reading Student C's statement, she considered what she reported to be a concern, not an allegation of abuse. She stated that this instruction was given because there was no merit to the concerns that the CNA student disclosed. The Regional Clinical Director stated that the ADM never stated that there was an allegation of abuse. The Regional Clinical Director stated that if there is a complaint of abuse, it is customary for them to investigate and immediately notify HHSC. She stated she was unaware if the term abuse was used when the concerns were made. She stated that the ADM had been trained on the abuse policy and is the abuse coordinator. She stated she felt comfortable with the ADM interpreting if there was an allegation of abuse. She stated that the ADM received the basic abuse training that all staff receive, but she was unaware of any additional training he may have received as the abuse coordinator. The Regional Clinical director stated she read Student C's statement and considered it a grievance. She stated that it was a strange situation because she is unsure if something is going on in the facility where the staff may be against CNA A. She stated that the ADM was responsible for reporting to HHSC. She said the purpose of reporting all allegations to HHSC was so they (HHSC) could come out and ensure that the facility followed the correct protocol to prevent abuse. She stated the reason the allegations of abuse were not reported was because they were considered a grievance and not an allegation of abuse. During an interview on 1/29/25 at 11:17 AM, Student C stated that 1/10/25 she graduated from CNA school. She stated that her experience at the NF was challenging. She stated that on the previous Tuesday (01/7/25) before graduation, she observed CNA B perform perineal care on Resident #3. She stated she observed her partially clean and not put cream on her buttocks. She stated that CNA B would not put the cream on Resident #3, so she retrieved the cream. She stated that CNA B thanked her, and when she went to put the cream on Resident #3, it appeared that CNA B forcibly put the cream in Resident #3 buttocks, and when she removed her hand, there was feces on CNA B's gloves, indicating that Resident #3 was not clean. Student C said CNA B did not attempt to reclean Resident #3. She stated that the next day (1/08/25), while she was feeding Resident #1, CNA A took over feeding Resident #1. Student C stated that she observed CNA A provide at least two large spoonful of mashed potatoes and other unknown sauces and feed them to Resident #1. Student C stated that when CNA A attempted to give her another heaping spoonful of food, Resident #1 appeared to start choking and spit the food out on her clothing protector. Student C stated she provided Resident #1 with a drink, which seemed to help her. She stated that CNA A was feeding Resident #1 all the while eating her own lunch in between providing Resident #1 bites of food. She stated that CNA A threw Resident #2 in the bed the same day. She stated she felt bad for the residents at the NF. She stated that Resident #2 told CNA A she was moving too fast and was crying. Student C stated she felt bad for all the residents at the NF because of the treatment she saw. She stated she went to CNA D, who told her she would have to report what she observed and showed her where to go. She stated she went to the ADON office on her first day. She stated that she made herself clear that she wanted to report abuse. She said the ADON told her she would have to get the ADM as she could not take a statement of that nature herself. She stated that when the ADON retrieved the ADM, they passed CNA A and told her, After this, we will need to talk. She stated that CNA A attempted to walk with the ADON and ADM, but the ADON stopped her. Student C said this made her feel uncomfortable as this would make it obvious that she was the one making the report of abuse. She stated they went to the office, and she reported what she had experienced, including the alleged allegations of abuse with Resident #1 ,#2, and #3. She stated that in the presence of the ADM and ADON, she made herself clear that she was alleging that Resident #1, #2, and #3 had been abused. She stated that she was asked to write a statement. She stated she was placed in the room next to the ADM office and could hear him sucking his teeth and breathing hard as if he was irritated. She stated that this treatment caused her not to focus on her statement as much. She stated that staff were coming in and out, and the ADM would come and ask her if she was done frequently. She stated that she did not include names or the words abuse or neglect because she was instructed by the ADM to only write what she observed. She stated that the tone of the environment set by the ADON and ADM made her rush and forget that she had another incident to report about CNA A. She said that CNA A had made an inappropriate comment to an unknown resident while showering him but did not want to say anything further because she already felt she had caused enough trouble. She stated that while reporting what she observed with Resident #1, #2, and #3, she (Student C) had become emotional and started crying. She stated that no one followed up with her about what she reported. She said she did not consider what she reported a grievance. She said she had received training on ANE during certified nurses aide training from the school but only attended the NF for hands on training with the residents. Record review of the email, dated 1/29/25, forwarded by the Regional Clinical Director revealed the following: Student C's witness statement was attached. The ADM emailed Student C's witness statement to Regional Clinical Director and reported that a student had complaints about staff care. Record review of Student C's handwritten statement, dated 1/9/25, revealed the following: December 7, 2025 I witness CNA B not cleaning the patient (Resident #3) in room private area right. She also did not use diaper rash medicine and when I brought it to her and told her to use it she placed it on her hand and forcefully shoved her hand in the lady's legs. The lady was in so much pain she yelled. January 8, 2025 I witnessed CNA A put a over amount of food into the mouth of a patient (Resident #1) who couldn't move and was rushing feeding her. The lady choked so I gave her kool-laid. January 9, 2025 I witnessed CNA A chuck Resident #2 on the bed. CNA A was in a hurry due to trying to leave early. Record review of CNA A's handwritten statement, dated 1/08/25, revealed the following: I, CNA A, was feeding residents and it was said I over feed, but I truly feel that I over did it, but I will be careful and safe. Record review of CNA A's handwritten statement, dated 1/09/25, revealed the following: I, CNA A, had 4 students with me to put Resident #2 to bed as asked by my nurse. As I stood her up I smelled her, so I got her brief and wipes and changed her while she was standing when I assisted her to bed. There were no provider investigation reports available for review that involved Resident #1, #2 or #3 as of 1/28/25. Record review of CNA B's handwritten statement, dated 1/07/25, revealed the following: Tuesday January 7th the students asked me for help with Resident #3, so I came to help. I let them know as I was helping that she's (Resident #3) sensitive so when you move her even just a little it hurts her. She (Resident #3) was a little red. It was the last round. I didn't have cream so I was gonna let night shift know she was red so they could put some on her but one of the student aids went and got some cream so I did put dome on her after she was changed. Record review of the facility's investigation report, dated 1/11/25, revealed the following: The investigation from the student was completed and the conclusion did not show any abuse or neglect. The staff need to be in-serviced on taking their time and more personal care when caring for residents. Safe surveys were completed by the Licensed Social Worker on other residents down the hall and no complaint made at this time. The staff (CNA B) that was in question about her perineal care technique: had stated to the student before they went in that the resident will scream out when you touch her in any manner. The staff (CNA A) that put Resident #2 to bed, stated she did not chuck as stated or do any type of transfer that would be considered abuse at that time. It may have seemed rough to the student. The staff (CNA A) that was feeding the resident (Resident #1) stated she was giving her large spoons, but that was normal for the resident (Resident #1) and she did not choke; and if so the nurse would have intervened. Record review of LVN E's handwritten statement, dated 1/09/25, revealed the following: Head to toe skin assessment performed on Resident #2. One old bruise noted to back of right arm, measuring 1 cm by 1.5 cm , and greenish in color. Residents skin is warm/dry to touch. Skin turgor elastic (ability to stretch and return to normal). No abnormalities noted, no other skin breakdown noted. No rashes/lesions noted to skin. Record review of facility's inservice overview, dated 1/10/25, revealed that staff were inserviced on the following: Customer service: Respect resident's rights, respect their privacy and show compassion with care Direct care Staff: Take your time with personal care, be gentle and use caution with care during transferring, assisting with meals and bathing. Record review of a total of 6 safe surveys, dated 1/10/25, revealed the following: No resident reported feeling unsafe, abused or handled roughly. Record review of facility employee training, dated 1/10/25, revealed the following: CNA B was trained on perineal care technique. Record review of facility employee training, dated 1/10/25, revealed the following: CNA A was trained on transfer technique and assisting residents with feeding. Record review of the facility policy, Filing Grievances, revised December 2024, revealed: Policy Statement Our facility will assist residents, their representatives (sponsors), other interested family members, or resident advocates in filing grievances or complaints when such requests are made. Any resident, his or her representative (sponsor), family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, theft of property, etc., without fear of threat or reprisal in any form. The resident, or person filing the grievance and/or complaint in behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. Such report will be made orally by the administrator, or his or her designee, within 3 working days of the filing of the grievance or complaint with the facility. A written summary of the report will also be provided to the resident, and a copy will be filed in the business office. Record review of the facility grievance log dated from November 2024-January 2025 did not include a concern involving Resident #1, #2 or Resident #3. Record review of the facility policy, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigation, revised April 2021, revealed: Policy Statement All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations). Policy Interpretation and Implementation If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to tl1e following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility; Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Reporting Results of Investigations The administrator, or his/her designee, provide the appropriate agencies or individuals listed above witl1 a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.

Based on observations, interviews, and record review, the facility failed to ensure that each residents environment remained as free from accident hazards as possible for 2 of 27 residents (Resident #12, Resident #28,) and reviewed for accidents. 1. The facility failed to ensure 3 resident rooms (rooms [ROOM NUMBER]) did not have electrical outlets protruding from the wall. 2. The facility failed to ensure 1 resident room (room [ROOM NUMBER]), where Resident #12 resided, did not have an electrical outlet protruding from the wall with exposed wires. Resident #12 had a BIMS score of 03, indicating she had severe cognitive impairment, and she was able to self-ambulate in her wheelchair. This failure could place residents at risk for fires, physical harm, electrocution, pain, mental anguish, emotional distress, and injury. Findings included: Resident #12 Record Review of Resident #12's face sheet dated 12/04/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: unspecified dementia (loss of thinking, remembering, and reasoning interferes with daily life activities), general anxiety disorder (feeling of fear, dread, and uneasiness) and unsteadiness on feet. Record review of Resident #12's comprehensive MDS assessment dated [DATE] revealed a BIMS score of 03 which indicated Resident #12 had severe cognitive impairment. The MDS further revealed Resident #12 used a manual wheelchair and was independent in the ability to wheel at least 150 feet in a corridor or a similar space. Observation on 12/03/24 at 3:19 PM revealed an electrical outlet detached and hanging from the wall in room [ROOM NUMBER] on A side. Access to exposed wires was noted in the back of the electrical outlet. A privacy curtain was observed hanging between the hanging electrical outlet and between the wall. A chair and a card table were noted in place of where a bed would be on A side of room [ROOM NUMBER]. Resident #28 Record Review of Resident #28's face sheet dated 12/09/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: chronic respiratory failure (breathing difficulties), major depressive disorder (mood disorder), and cognitive communication deficit. Record review of Resident #28's comprehensive MDS assessment dated [DATE] revealed a BIMS score of 13 which indicated Resident #28 had intact cognition. The MDS further revealed Resident #28 used a manual wheelchair and required substantial assistance in the ability to wheel at least 150 feet in a corridor or a similar space. Observation on 12/03/24 at 3:39 PM revealed an electrical outlet box hanging from the wall in room [ROOM NUMBER] on A side by the door. Interview on 12/03/24 at 6:42 AM, the ADM stated the Maintenance Supervisor has been out sick for the past 2 days but should be back to work tomorrow. The ADM stated the Maintenance Supervisor was supposed to make rounds weekly on rooms to check for preventative maintenance issues. The ADM stated he will go and check rooms himself daily for any maintenance issues. The ADM stated there is a maintenance work order book on each hall and the staff are to write all of their maintenance concerns in the work order book. Interview on 12/03/24 at 8:48 PM, the ADM stated Resident #12 would be moved to a different room for the night and an electrician would be at the facility in the morning to work on the hanging/protruding electrical outlets. The ADM stated tape would be placed across room [ROOM NUMBER] so no other staff or residents enter the room before the electrician got to the facility. Observation on 12/03/24 at 8:58 PM, Resident #12 was transferred to a room on A-Hall for the night. No concerns noted with transfer of resident. Observation on 12/04/24 at 10:08 AM, an electrician was noted working on the hanging electrical outlet in room [ROOM NUMBER]. The electrician stated there was a possibility for electrical arcing due to the exposed wires on the hanging electrical outlet box. Interview on 12/04/24 at 10:56 AM, the ADM stated there was a maintenance order on 10/31/24 for room [ROOM NUMBER] regarding an electrical outlet and it was in regard to a different outlet. The ADM stated the hanging electrical outlet in room [ROOM NUMBER] on the head wall on A side was missed when the other electrical outlet was removed from her room. Observation on 12/05/24 at 9:02 AM revealed the electrical outlet in room [ROOM NUMBER] attached to the wall and no longer hanging. Observation on 12/05/24 at 1:28 PM revealed the electrical outlet in room [ROOM NUMBER] was firmly attached to the wall. Observation on 12/05/24 at 1:32 PM revealed the electrical outlet in room [ROOM NUMBER] was no longer protruding from the wall. Record review on 12/05/24 at 2:00 PM of the Electronic Medical Record Bulletin on Point Click Care revealed a message to all staff regarding Accident Hazards and Electrical Outlets. Record review of the facility policy and procedure titled Safety Precautions, Electrical with a revised date of 01/11 reflected the following: Policy Statement - Electrical safety precautions have been established for all personnel to follow. Policy Interpretation and Implementation - The following electrical safety precautions have been established for all personnel to follow. These precautions are not all-inclusive. Others may be added or amended as necessary. 5. Report any plug that is broken, bent, loose. 7. Report all worn, cut, frayed, spliced, exposed, or burned power cords. 18. Report any and all unsafe electrical hazards to your supervisor immediately Record review of the facility policy and procedure titled Hazardous Areas, Devices and Equipment with a revised date 07/17 reflected the following: Policy Statement - All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Record review of the facility policy and procedure titled Accidents/Incidents with a revised date of 04/13 reflected the following: Policy Statement - Our facility shall provide a safe and secure environment for staff and residents

Based on observations, interviews, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relayed the call directly to a centralized staff work area for 14 of 74 residents (Resident #3, #11, #12, #19, #20, #24, #28, #38, #40, #44, #47, #58, #62, and #65) reviewed for call lights. The facility failed to ensure residents were equipped with a fully functioning call light system in room [ROOM NUMBER] and room [ROOM NUMBER]. Resident #11 had a diagnosis of type 2 diabetes and COPD (Chronic obstructive pulmonary disease), both which would require immediate attention if Resident #11 needed oxygen, or his blood sugar fell too low or got too high. Resident #12 had a diagnosis of type e2 diabetes which would require immediate attention if blood sugar were to get too high or too low. There were no frequent rounds being completed. These failures could place residents at risk of injury, pain, hospitalization , and a diminished quality of life. An Immediate Jeopardy was identified on 12/5/24/ The IJ template was provided to the facility Administrator on 12/5/24 at 4:48 PM. While the immediate jeopardy was removed l on 12/6/24 , the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent future concerns. Findings included: Resident #3: Record review of an Admission Record dated for Resident #3 shows an [AGE] year-old male with an original admitted [DATE] and a readmitted [DATE] with diagnoses of epilepsy (disorder of the brain characterized by repeated seizures), altered mental status, pain, lack of coordination, feeding difficulties, history of pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot), muscle weakness, insomnia (persistent problems falling asleep), depression, acid reflux, lennox-gastaut syndrome (a rare and severe form of epilepsy that starts in early childhood), eosinophilic esophagitis (chronic allergic immune system disease that affects the esophagus), abdominal hernia (any protrusion of intestine or other tissue through a weakness or gap in the abdominal wall), osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bone wears down) (difficulty swallowing), dysphagia, repeated falls. Record review of a Significant Change in Status MDS (Minimum Data Set) assessment dated [DATE] for Resident #3 indicated a BIM (Brief Interview for Mental Status) of 10 meaning Resident #3 had moderate cognitive impairment. Record review of Resident #3's care plan dated 6/5/2024 indicated Resident #3 had ADL self-care performance deficit due to LENNOX-GASTAUT Syndrome, Epilepsy with interventions of encourage resident to use the call for assistance. If the resident is unable to utilize the call light, staff will provide frequent visual checks. Record review of Resident #3's care plan dated 6/5/2024 indicated Resident #3 had risk for falling due to co-morbid. conditions and impaired mobility with the interventions of call light is within reach and encourage me to use it for assistance as needed. Record review of Resident #3's care plan date revised on 10/3/2024 indicated Resident #3 had risk for Alteration in musculoskeletal status due to contusion of lower back with the interventions of anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Resident #11: Record review of an Admission Record dated for Resident #11 shows an [AGE] year-old male with an original admitted [DATE] and a readmitted [DATE] with diagnoses of muscle weakness, unsteadiness on feet, hypokalemia, elevated white blood count, age-related physical disability, schizoaffective disorder, neuroleptic induced parkinsonism, type 2 diabetes, major depressive disorder, hypothyroidism, anxiety disorder, hyperlipidemia, paranoid schizophrenia, high blood pressure, chronic obstructive pulmonary disease, benign prostatic hyperplasia. Record review of a Significant Change in Status MDS (Minimum Data Set) assessment dated [DATE] for Resident #11 indicated a BIMS (Brief Interview for Mental Status) of 14 meaning Resident #11 had minimum cognitive impairment. Record review of Resident #11's care plan dated 6/5/2024 indicated Resident #11 had is at moderate is risk for falls due to Psychotropic use, Antidepressant use, and Antianxiety use with the interventions of call light is within reach and encourage him to use it for assistance as needed. Resident #11 needs prompt response to all requests for assistance. Record review of Resident #11's blood sugar for the dates between 4/9/2024 through 12/19/2024, revealed: 12/11/2024 at 19:58 with blood sugar of 78 mg/dl 11/24/2024 at 16:51 with blood sugar of 77 mg/dl 11/23/2024 at 20:37 with blood sugar of 77 mg/dl 11/14/2024 at 20:55 with blood sugar of 76 mg/dl 11/14/2024 at 20:30 with blood sugar of 76 mg/dl 11/08/2024 at 21:31 with blood sugar of 79 mg/dl 11/07/2024 at 10:15 with blood sugar of 68 mg/dl 11/05/2024 at 20:55 with blood sugar of 79 mg/dl 11/03/2024 at 16:46 with blood sugar of 75 mg/dl 11/02/2024 at 16:36 with blood sugar of 79 mg/dl 10/22/2024 at 20:26 with blood sugar of 72 mg/dl 10/16/2024 at 20:56 with blood sugar of 76 mg/dl 10/13/2024 at 21:22 with blood sugar of 77 mg/dl 10/12/2024 at 20:49 with blood sugar of 72 mg/dl 10/11/2024 at 11:31 with blood sugar of 79 mg/dl 10/10/2024 at 10:56 with blood sugar of 66 mg/dl 9/28/2024 at 19:45 with blood sugar of 75 mg/dl 9/15/2024 at 19:34 with blood sugar of 65 mg/dl 9/10/2024 at 20:55 with blood sugar of 74 mg/dl 8/30/2024 at 10:07 with blood sugar of 76 mg/dl 8/3/2024 at 19:21 with blood sugar of 77 mg/dl 7/15/2024 at 20:20 with blood sugar of 74 mg/dl 7/10/2024 at 11:51 with blood sugar of 73 mg/dl 7/09/2024 at 11:33 with blood sugar of 71 mg/dl 7/08/2024 at 11:08 with blood sugar of 76 mg/dl 6/29/2024 at 10:18 with blood sugar of 75 mg/dl 6/21/2024 at 21:18 with blood sugar of 75 mg/dl 6/14/2024 at 11:30 with blood sugar of 67 mg/dl 6/3/2024 at 13:10 with blood sugar of 79 mg/dl 6/1/2024 at 20:01 with blood sugar of 75 mg/dl 5/30/2024 at 16:41 with blood sugar of 67 mg/dl 5/27/2024 at 11:47 with blood sugar of 79 mg/dl 5/25/2024 at 20:23 with blood sugar of 77 mg/dl 5/24/2024 at 11:33 with blood sugar of 79 mg/dl 5/18/2024 at 15:09 with blood sugar of 73 mg/dl 5/18/2024 at 10:50 with blood sugar of 61 mg/dl 5/17/2024 at 10:28 with blood sugar of 76 mg/dl 5/10/2024 at 11:14 with blood sugar of 73 mg/dl 5/2/2024 at 11:24 with blood sugar of 69 mg/dl 5/1/2024 at 19:37 with blood sugar of 68 mg/dl 5/1/2024 at 11:33 with blood sugar of 79 mg/dl 4/26/2024 at 11:10 with blood sugar of 57 mg/dl 4/24/2024 at 10:23 with blood sugar of 57 mg/dl 4/21/2024 at 11:26 with blood sugar of 59 mg/dl 4/19/2024 at 10:35 with blood sugar of 59 mg/dl 4/13/2024 at 16:44 with blood sugar of 73 mg/dl 4/11/2024 at 19:51 with blood sugar of 76 mg/dl 4/9/2024 at 11:25 with blood sugar of 58 mg/dl Record review of Resident #11's Progress Note dated 07/10/2024 stated: Spoke to FNP this morning about changing Resident #11's sliding scale insulin to start at 200. He bottoms out if we give any insulin below that. Received order to discontinue all sliding scale insulin. Record review of Resident #11's Progress Note dated 03/05/2024 stated: This nurse notified, NP regarding this resident having fluctuating blood glucose levels, with no insulin orders or SSI orders in place. This nurse notified Nurse practitioner, insulin and SSI was discontinued in hospital. New order placed; Start back on SSI, with Novolin R 100 units/ML and monitor, per NP, DON, and ADON, notified. Resident #12: Record review of an Admission Record dated for Resident #12 shows a [AGE] year-old female with an admitted [DATE] with diagnoses of dementia, anxiety, unsteadiness on feet, urinary tract infection, schizoaffective disorder, pain, feeding difficulties, muscle weakness, cognitive communication deficit, age-related disability, type 2 diabetes, hyperlipidemia, high blood pressure, A-Fib, arthritis. Record review of an Annual MDS (Minimum Data Set) assessment dated [DATE] for Resident #12 indicated a BIMS (Brief Interview for Mental Status) of 3 meaning Resident #12 had severe cognitive impairment. Record review of Resident #12's care plan dated 6/5/2024 indicated Resident #12 had is at moderate is risk for falls. due co-morbid conditions and impaired mobility with interventions of call light is within reach and encourage me to use it for assistance as needed. Resident #19: Record review of an Admission Record dated for Resident #19 shows an [AGE] year-old female with an admitted [DATE] with diagnoses of Alzheimer's disease, unsteadiness on feet, anxiety, atrial flutter, paroxysmal tachycardia, chronic obstructive pulmonary disease, psychotic disorder, hyperlipidemia, major depression, neuromuscular dysfunction, feeding difficulties, aphasia, abnormalities of gait and mobility, muscle weakness, lack of coordination, cognitive communication deficit, pain in joint, history of falling. Record review of an Annual MDS (Minimum Data Set) assessment dated [DATE] for Resident #19 indicated a BIMs (Brief Interview for Mental Status) of 3 meaning Resident #19 had severe cognitive impairment. Record review of Resident #19's care plan dated 6/5/2024 indicated Resident #19 had oxygen Therapy due to COPD O2 @ 2-3 Liters Per Minute via NC PRN to keep sats at 90% with interventions of provide reassurance and allay anxiety: Have an agreed-on method for the resident to call for assistance (e.g., call light, bell). Stay with the resident during episodes of respiratory distress. Record review of Resident #19's care plan dated 12/5/2024 indicated Resident #19 had a handbell to use as an auditory alarm with the interventions of do frequent checks to ensure needs are met, ensure handbell is within reach and resident is aware of where the handbell is, ensure staff is aware of the handbell. Record review of Resident #19's care plan dated 5/15/2024 indicated Resident #19 had a risk for falls due to impaired mobility, cognition, and history of falls with interventions of call light is within reach and encourage resident to use it for assistance as needed. Resident needs prompt response to all requests for assistance. If resident is unable to utilize the call light staff will provide frequent visual checks. Record review of Resident #19's O2 SAT Summary between dates of 1/28/2022-10/5/2023, revealed that Resident #19 ran consistently low between 95-90 throughout the entire summary. Resident #20: Record review of an Admission Record dated for Resident #20 shows an [AGE] year-old female with an admitted [DATE] with diagnoses of dementia, hypothyroidism, hyperlipidemia, hearing loss, chronic kidney disease, atherosclerotic kidney disease, aortic valve stenosis, acid reflux, atopic dermatitis, osteoporosis, chronic kidney disease, stress incontinence, edema, proteinuria, history of falling. Record review of a Quarterly MDS (Minimum Data Set) assessment dated [DATE] for Resident #20 indicated a BIMS (Brief Interview for Mental Status) of 00 meaning Resident #20 was unable to recall information. Record review of Resident #20's care plan dated 12/12/2023 indicated Resident #20 had a risk for falling due to my co-morbid conditions and impaired mobility. Resident #24: Record review of an Admission Record dated for Resident #24 shows an [AGE] year-old male with an admitted [DATE] with diagnoses of cellulitis, pain, gastrostomy, muscle wasting, supraventricular tachycardia, seizures, allergic dermatitis, high blood pressure, anoxic brain damage, seborrheic dermatitis, high blood pressure, fasciculation, pain in joint, iron deficient anemia, moderate protein calorie malnutrition, anxiety, quadriplegia, acid reflux, constipation, contracture of right and left hand, muscle spasm, dysphagia, flatulence, aphasia, convulsions, traumatic brain injury. Record review of a Quarterly MDS (Minimum Data Set) assessment dated [DATE] for Resident #24 indicated a BIMs (Brief Interview for Mental Status) was left blank and incomplete. Record review of Resident #24's care plan date revised on 9/22/2019 indicated Resident #24 had a has a communication problem due to Head Injury, Weak or absent voice with the allegations of call light in reach. Record review of Resident #24's care plan date revised on 11/15/2024 indicated Resident #24 had a high risk for falls due to balance problems, poor trunk control, no purposeful movement, secondary to traumatic brain injury. Resident #28: Record review of an Admission Record dated for Resident #28 shows an [AGE] year-old female with an admitted [DATE] with diagnoses of chronic respiratory failure, major depression, cognitive communication deficit, pain in joint, muscle weakness, feeding difficulties, tinea cruris, candidiasis of vulva, anemia, hypothyroidism, type 2 diabetes, iron deficiency, morbid obesity, hyperlipidemia, insomnia, chronic pain syndrome, peripheral neuropathy, high blood pressure, diverticulosis, gout, plantar fascial fibromatosis, acute kidney failure, urge incontinence, post-menopausal bleeding, dizziness, injury of muscle and tendon of rotator cuff, urinary tract infection, dependence on supplemental oxygen. Record review of a Quarterly MDS (Minimum Data Set) assessment dated [DATE] for Resident #28 indicated a BIMS (Brief Interview for Mental Status) of 13 meaning Resident #28 had mild cognitive impairment. Record review of Resident #28's care plan dated 12/12/2023 indicated Resident #28 had a risk for falling due to co-morbid.conditions and impaired mobility with the allegations of call light is within reach and encourage me to use it for assistance as needed. Resident #38: Record review of an Admission Record dated for Resident #38 shows an [AGE] year-old female with an admitted [DATE] and an original admitted [DATE] with diagnoses of stroke, major depression, high blood pressure, type 2 diabetes, hyperlipidemia, chronic kidney disease, sciatica, hemiplegia & hemiparesis, pain, muscle weakness, lack of coordination, feeding difficulties, age-related physical disability. Record review of a Quarterly MDS (Minimum Data Set) assessment dated [DATE] for Resident #38 indicated a BIMS (Brief Interview for Mental Status) of 12 meaning Resident #38 had mild cognitive impairment. Record review of Resident #38's care plan dated 11/10/2024 indicated Resident #38 had a risk for risk for falling d/t my co-morbid conditions and impaired mobility with interventions of call light is within reach and encourage me to use it for assistance as needed. Resident #40: Record review of an Admission Record dated for Resident #40 shows an [AGE] year-old female with an admitted [DATE] with diagnoses of psychotic disturbance, wheezing, tachypnea, abscess of bursa, unspecified falls, drug induced dyskinesia, torsion dystonia, major depression, Huntington's disease, urinary incontinence, muscle weakness, dysphagia, abnormalities of gait and mobilities, lack of coordination, cognitive communication deficit. Record review of an Annual MDS (Minimum Data Set) assessment dated [DATE] for Resident #40 indicated a BIMS (Brief Interview for Mental Status) of 9 meaning Resident #40 had mild cognitive impairment. Record review of Resident #40's care plan dated 6/15/2022 indicated Resident #40 had behaviors such as physically and verbally aggressive when offered the services with interventions of ensure call light is in reach at all times. Record review of Resident #40's care plan date revised on 11/15/2024 indicated Resident #40 had a risk for falling due to my co-morbid conditions and impaired mobility with interventions of call light is within reach and encourage me to use it for assistance as needed. Record review of Resident #40's care plan dated on 12/5/2024 indicated Resident #40 had a bell in place of a call light. Resident #44: Record review of an Admission Record dated for Resident #44 shows an [AGE] year-old female with an admitted [DATE] with an initial admitted [DATE] with diagnoses of stroke, shortness of breath, anemia, hyperlipidemia, melena, chronic kidney disease, dementia, schizoaffective disorder, edema, dysphagia, unsteadiness on feet, iron deficiency anemia, acid reflux, dermatitis, abnormalities of gait and mobility, weakness, malaise, high blood pressure, aphasia, dysarthria, chronic embolism, pain in joint, muscle weakness, feeding difficulties, lack of coordination, reduced mobility. Record review of an Annual MDS (Minimum Data Set) assessment dated [DATE] for Resident #44 indicated a BIMS (Brief Interview for Mental Status) of 12 meaning Resident #44 had mild cognitive impairment. Record review of Resident #44's care plan dated 6/15/2022 indicated Resident #44 had a risk for falling due to my co-morbid conditions and impaired mobility with the interventions of call light is within reach and encourage me to use it for assistance as needed. Record review of Resident #44's care plan dated 10/2/2023 indicated Resident #44 had an actual fall with no injury with the interventions of all light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Record review of Resident #44's care plan dated 12/5/2024 indicated Resident #44 had a handbell to use as an auditory alarm. Record review of Resident #44's care plan dated 12/7/2022 indicated Resident #44 had an ADL self-care performance deficit r/t cerebral infarction with interventions of encourage Resident #44 to use the call for assistance. If the resident is unable to utilize the call light, staff will provide frequent visual checks. Record review of Resident #44's care plan dated 12/7/2022 indicated Resident #44 is at moderate risk for falls due to impaired mobility with interventions of Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Resident #47: Record review of an Admission Record dated for Resident #47 shows an [AGE] year-old female with an admitted [DATE] with diagnoses of fracture of sacrum, pain in joint, muscle weakness, urinary tract infection, nausea with vomiting, hypo-osmolality, major depression, anxiety, high blood pressure, atherosclerotic heart disease, pulmonary hypertension, emphysema, respiratory failure, sacrococcygeal disorders, acute kidney failure. Record review of an Admission MDS (Minimum Data Set) assessment dated [DATE] for Resident #47 indicated a BIMS (Brief Interview for Mental Status) of 10 meaning Resident #47 had moderate cognitive impairment. Record review of Resident #47's care plan dated 4/20/2023 dated on 11/11/2024 indicated Resident #47 was at risk for falls. Interventions included to place Resident #47's call light within reach and encourage to use it for assistance as needed. Resident #58: Record review of an Admission Record dated for Resident #58 shows an [AGE] year-old female with an admitted [DATE] with an original admitted [DATE] with diagnoses of Alzheimer's disease, history of UTI's, restlessness and agitation, intertrochanter fracture of left femur, anxiety, insomnia, unsteadiness on feet, unspecified fall, pain in joint, muscle weakness, lack of coordination, cognitive communication deficit, feeding difficulties, hypothyroidism, dementia, glaucoma, high blood pressure, acid reflux, osteoporosis. Record review of an Significant Change in Status MDS (Minimum Data Set) assessment dated [DATE] for Resident #58 indicated a BIMS (Brief Interview for Mental Status) of 3 meaning Resident #58 had severe cognitive impairment. Record review of Resident #58's care plan dated 4/20/2023 date revised on 10/28/2024 indicated Resident #58 was high at risk for falls due to confusion. Interventions included to place Resident #58's call light within reach and encourage to use it for assistance as needed. Record review of Resident #58's care plan date revised on 7/7/2023 indicated Resident #58 had a cognitive communication deficit due to Alzheimer's with the interventions of Call light in reach. Resident #62: Record review of an Admission Record dated for Resident #62 shows an [AGE] year-old female with an admitted [DATE] with diagnoses of urinary tract infection, bipolar disorder, anxiety, hypokalemia, dementia, diverticulitis, irritable bowel syndrome, pain in joint, muscle weakness, unsteadiness on feet, lack of coordination, cognitive communication deficit, feeding difficulties, hypothyroidism, hyperlipidemia, depression, insomnia, hearing loss, high blood pressure, atherosclerosis of aorta, diarrhea, fracture of sacrum, left ilium, left pubis, falls. Record review of a Significant Change in Status MDS (Minimum Data Set) assessment dated [DATE] for Resident #62 indicated a BIMS (Brief Interview for Mental Status) of 3 meaning Resident #62 had severe cognitive impairment. Record review of Resident #62's care plan date revised on 9/2/2024 indicated Resident #62 was at risk for falls. Interventions included to place Resident #62's call light within reach and encourage to use it for assistance as needed. Record review of Resident #62's care plan date revised on 11/14/2024 indicated Resident #62 had a witnessed actual fall with NO INJURIES ON 11/13 with interventions of call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Record review of Resident #62's care plan date revised on 12/5/2024 indicated Resident #62 had a handbell to use as an auditory alarm with the interventions of ensure handbell is within reach and resident is aware of where the handbell is. Resident #65: Record review of an Admission Record dated for Resident #65 shows an [AGE] year-old female with an admitted [DATE] with diagnoses of atherosclerosis of coronary artery bypass, pain, muscle weakness, unsteadiness on feet, lack of coordination, candidiasis, hyperthyroidism, type 2 diabetes, hyperlipidemia, depression, high blood pressure, angina pectoris, acid reflux, gout, syncope and collapse, history of falling, presence of cardiac pacemaker, essential tremor, heart failure, stroke, acute kidney failure. Record review of an Admission MDS (Minimum Data Set) assessment dated [DATE] for Resident #65 indicated a BIMS (Brief Interview for Mental Status) of 10 meaning Resident #62 had moderate cognitive impairment. Record review of Resident #65's care plan date revised on 10/8/2024 indicated Resident #65 was at risk for falls due to gait problems. Interventions included to place Resident #65's call light within reach and encourage to use it for assistance as needed. Record review of Resident #65's care plan date revised on 10/9/2024 indicated Resident #65 had an alteration in musculoskeletal status due to other specified disorders of bone density and structure with interventions of anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. During an interview with Resident #44 on 12/3/2024 at 11:10 AM. Resident #44 stated that when the call light is used that Resident #44 is not helped a lot of the time. Resident #44 stated that the call light was used on 12/12/2024 to get assistance with a glass of water and no one ever came to help. Resident #44 stated that she had fallen back to sleep without any water. During an interview with Resident #28 on 12/3/2024 at 11:35 AM. Resident #28 stated that it takes the staff a long time to answer the lights and sometimes they do not answer at all. Resident #28 stated that there are times that she is left wet for a while until someone comes to help. Resident #28 stated that it makes her feel like her needs are not important. During night observations and interview on 12/4/2024 at 10:37 PM, Observed room for Resident #44 was on outside of her door but was no sound was triggered at the nurse's station. Resident #44 stated that it takes a long time for staff to answer the call lights. During an interview with LVN C on 12/4/2024 at 10:52 PM. LVN C stated that the call lights had been messed up for a while. LVN C stated that the staff has to make sure to complete rounds because some of the rooms do not trigger a light or a sound. LVN C stated that maintenance had been notified a long time ago and it continues to not be fixed. During an interview with CNA B on 12/4/2024 at 11:01 PM. CNA B stated that the call lights do not work correctly. CNA B stated that on some of the resident's rooms if you trigger the call light in one room it will also trigger in another room. CNA B stated that most of the time it is hard to get to the resident's needs if she does not know that the call light is being triggered. During an interview with LVN E on 12/5/2024 at 10:00 AM. LVN E stated that when she pushes the call light in room [ROOM NUMBER], it also triggers the light in room [ROOM NUMBER] at the same time. LVN E stated that when she pushes the call light in room [ROOM NUMBER], it also triggers the light in room [ROOM NUMBER]. LVN E stated that the call light in room [ROOM NUMBER] only lights up outside of the room but does not trigger a sound at the nurse's station. LVN E showed Surveyor that all these call lights were not working properly. LVN E stated that the call lights had been not working for about 4 to 6 months. LVN E stated that maintenance requests had been completed. Interview with MA B on 12/5/2024 at 11:18 AM. MA B stated that the call lights had not worked for about 4 to 5 months. MA B stated that it is hard to tell who needs help. MA B stated that the staff has to make more frequent rounds. MA B stated that a resident could get hurt if the staff is not aware that the resident needs help and they try to help themselves. During an observation of expanded sample for call lights on 12/5/2024 beginning at 1:48 PM revealed: During observations it was learned that no other method for the residents to alert the staff. Call lights that had a light but not sounding at the nurse's station: room [ROOM NUMBER] A&B, 103 A&B, 125 A, 131 A, 141 A&B, 146 A Rooms with no call light: room [ROOM NUMBER] had no call light. It had the call light cord plugged in and hanging down and at the end of the cord had frayed wired with no call light button attached. Rooms with lights being triggered in other rooms at the same time: In room [ROOM NUMBER] the call light is triggered and also triggers the light in room [ROOM NUMBER] at the same time. In room [ROOM NUMBER] if the call light is triggered it also triggers the light in 109. Call Light that does not work: room [ROOM NUMBER] some of the time the light will work and some of the time the light would not work. During an interview with Resident #11 on 12/5/2024 at 2:38 PM. Resident #11 stated that sometimes the call light works and sometimes it does not. Resident #11 stated that the call light does not work right and sometimes he is not able to get the help that he needs because the call light is not working. Resident #11 stated that it had been not working for about six months. Resident #11 stated that he never knows when it is working and when it is not. Resident #11 stated that the only way to tell that the call light is not working is no one shows up to help. Resident #11 stated that he had diabetes and had issues with his blood sugars falling or at times it will get too high and those times help is needed. Resident #11 stated that help is also needed for brief changes. Resident #11 stated that if no one comes to help he just has to suffer through it. Resident #11 stated that there are times where help is really needed. Resident #11 stated that one time Resident #11's blood sugar had fallen severely low and used the call light but noticed it had been a long time and no one came to help. Resident #11 stated that when Resident #11 started feeling ill because of the drop he yelled out for help and then someone came to help. Resident #11 stated that what would happen if no one had come in to help. Resident #11 stated that he feared that he was going to die that day. During an observation of Resident #11 call light on 12/5/2024 at 3:01 PM showed the call light plugged into port B that did not work. The call light did not light up outside the door and it did not sound at the nurse's station. During an interview with the Administrator on 12/09/2024 at 11:00 AM. The Administrator stated that he was assuming that the maintenance was taking care of the call light situation. The Administrator stated that the Maintenance guy had missed some work due to illness. The Administrator stated that he was not sure how long the call light situation had occurred. The Administrator stated that the negative outcome for the call light not fully functioning is the resident would not be able to get their needs met. Record review of a facility policy titled, Call System, Resident, dated September 2022 stated: Policy Heading: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member of a centralized workstation. Policy Interpretation and Implementation: 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. 2. Call system communication may be audible or visual. The system may be wired or wireless. 3. The resident call system remains functional at all times. If audible communication is used, the volume is maintained at an audible level that can be easily heard. If visual communication is used, the lights remain functional. 4. If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communications that is usable for the resident is provided and documented in the care plan. 5. The resident call system is routinely maintained and tested by the maintenance department. 6. Calls for assistance are answered as soon as possible, but no later than 5 minutes. Urgent requests for assistance are addressed immediately. 7. Call light response times are reviewed as part of the QAPI program. Record review of facility maintenance log dates from 09/20/2024-10/11/2024 stated: 1. 9/20/2024: 126 B- (Description or issue) call light does not work, (Completion Date) stated: repaired 9/23/2024. 2. 9/20/2024: 141 B- (Description or issue) call light does not sound, (Completion Date) stated: Do not know what to do about this. 3. 10/10/2024: 134 B- (Description or issue) call light needs to be fixed, (Completion Date) stated: needs new call card. Record review of Resident Council Minutes dated September 09/03/2024, 10/1/2024, and 11/4/2024 all stated: Night Aides not doing their 2-hour rounds. This failure was determined to be an Immediate Jeopardy on 12/05/2024 at 4:48 p.m The Administrator was notified. The Administrator was provided with the IJ template on 12/05/2024 at 4:48 PM. The following Plan of Removal submitted by the facility was accepted on 12/06/2024 at 9:18 AM: Plan of Removal: PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY F919 Impact Statement Call System Facility failed to provide a functioning call system in identified rooms to allow alerting of staff for assistance and communication. Identify residents who could be affected. Residents in [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care, were provided such care, consistent with professional standards of practice for 3 (Resident #50, Resident #68, Resident #35) of 7 residents reviewed for respiratory care. The facility failed to follow their policy for proper storage of oxygen tubing for Resident #50, Resident #68, and Resident #35. This failure could place residents at risk for respiratory compromise and infection. Findings included: Resident #50 Review of Resident #50's face sheet revealed a [AGE] year-old female with an original admitted [DATE] with the following diagnoses: Atherosclerotic Heart Disease (disease of the heart's major vessels), Cognitive Communication Deficit (inability to effectively communicate needs), Chronic Obstructive Pulmonary Disease (airflow blockage and breathing-related problems), Type II Diabetes Mellitus (abnormally elevated blood sugar levels), Heart Failure (heart condition), Kidney Failure (condition causing kidneys to not function properly ), Gastroesophageal Reflux Disease (digestive condition), and Hypertension (high blood pressure). Record review of Resident #50's significant change MDS dated [DATE] revealed a BIMS score of 15, indicating the resident was cognitively intact. Section O - Special Treatments, Procedures and Programs revealed Resident #50 used oxygen therapy while a resident. Record review of Resident #50's comprehensive care plan, dated 10/15/24, revealed resident #50 may use oxygen therapy related to Chronic Obstructive Pulmonary Disease. Record review of Resident #50's current Physician Orders dated 12/09/24 revealed an order for oxygen to be administered at 2-3 liters per minute per nasal cannula (tube in nostrils) every shift as needed. During an observation and interview on 12/03/24 at 9:01 AM, Resident #50 was resting in bed. The resident's oxygen cannula and tubing were observed laying on the floor. The resident's oxygen concentrator was on at 3 liters per minute. No bag for storage of oxygen tubing was observed. Resident #50 stated staff usually change the tubing and humidifier, but she did not recall staff placing a bag to store the oxygen tubing in while it was not in use. Resident #50 stated, that is probably why it ends up on the floor. During an observation on 12/06/24 at 10:47 AM, there was no bag for oxygen tubing storage observed in the room of Resident #50. Resident #68 Record review of Resident #68's face sheet revealed a [AGE] year-old male with an admitted [DATE] with the following diagnoses: Dementia (loss of thinking, memory, and reasoning skills), Atrial Fibrillation (irregular heart rate which causes poor blood flow), Type II Diabetes Mellitus (abnormally elevated blood sugar levels), Depression, Malignant Neoplasm of lung (lung cancer), and Hypertension (high blood pressure). Record review of Resident #68's significant change MDS dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment. Section O - Special Treatments, Procedures and Programs revealed Resident #68 used oxygen therapy while a resident. Record review of Resident #68's current Physician Orders dated 12/09/24 revealed an order for oxygen to be administered at 2 liters per minute as needed for shortness of breath. During an observation on 12/03/24 at 9:07AM, Resident #68 was out of the facility. The resident's oxygen cannula was observed laying across the bed with the tubing laying on the floor. No bag for storage of oxygen tubing was observed. During an observation and interview on 12/03/24 at 11:26 AM, Resident #68 was observed sitting on the side of his bed with oxygen on at 2 liters per minute via nasal cannula. The resident stated, to his knowledge, there was not a bag for storage of his oxygen tubing when it was not in use. The resident stated, I usually just put it wherever when I take it off. I don't know where it's supposed to go. Resident #35 Review of Resident #35's face sheet revealed a [AGE] year-old male with an original admitted [DATE] with the following diagnoses: Chronic Kidney Disease (long-standing disease of the kidneys, leading to kidney failure) Atherosclerotic Heart Disease (disease of the heart's major vessels), Cognitive Communication Deficit (inability to effectively communicate needs), Chronic Obstructive Pulmonary Disease (airflow blockage and breathing-related problems), Type II Diabetes Mellitus (abnormally elevated blood sugar levels), Heart Failure (heart condition), Absence of kidney, Gastroesophageal Reflux Disease (digestive condition), and Dependence on Supplemental Oxygen. Record review of Resident #35's quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating the resident was cognitively intact. Section O - Special Treatments, Procedures and Programs revealed Resident #50 used oxygen therapy while a resident. Record review of #35's current Physician Orders dated 12/09/24 revealed an order for oxygen to be administered at 2-3 liters per minute as needed for Chronic Obstructive Pulmonary Disease. During an observation and interview on 12/03/24 at 9:01 AM, Resident #35 was in bed watching tv with oxygen on at 3 liters per minute via nasal cannula. Resident #35 had a motorized wheelchair with a portable oxygen tank attached. The cannula and tubing from the portable oxygen tank were observed laying on the floor. The resident stated he does not have a bag to place his oxygen tubing in. He stated staff usually change the tubing and humidifier bottle on Sunday nights, but they do not always bring a bag for the tubing to be stored in. No storage bag was observed on concentrator or portable oxygen tank. Resident #35 stated he does not have anywhere to put his oxygen tubing when he gets up. The resident stated, I usually just throw it over the bed or hang it on the back of the wheelchair but a lot of times it ends up on the floor. During an observation on 12/06/24 at 10:35 AM, Resident #35 was observed resting in bed with oxygen on at 3 liters per minute via nasal cannula. No bag was observed for oxygen tubing storage on concentrator or portable oxygen tank. Oxygen tubing from portable tank on the resident's wheelchair was observed touching the floor. During an interview on 12/06/24 at 10:36 AM with LVN A, she stated oxygen tubing should be kept in plastic bags when not in use and should be changed out with the tubing and humidifier bottles every Sunday on the night shift. She stated she was not sure why there would not be bags available in resident rooms who were on oxygen. She stated oxygen tubing should not be on the floor or be placed anywhere that it could become contaminated. She stated a potential negative outcome for failure to properly store oxygen tubing was infection. During an interview on 12/06/24 at 10:41 AM with CNA A, she stated the night shift was responsible to make sure bags were placed in the rooms of residents who were on oxygen. She stated she was assigned to the hall for Resident # 50, Resident #68 and Resident #35. She stated she had just returned from her days off and today was her first day back at work. She stated she had not checked the oxygen storage bags today because she had not had time yet. She stated bags should be checked daily and changed every Sunday night. She stated it was the responsibility of all staff to make sure bags were available for storage of oxygen tubing. She stated oxygen tubing should never be on the floor or anywhere that it could pick up germs. She stated she had been trained by the facility on proper oxygen tubing storage. She stated a potential negative outcome of failure to properly store oxygen tubing was infection. During an interview on 12/09/24 at 11:16 AM with the ADM, he stated he was not aware that residents requiring oxygen did not have storage bags for oxygen tubing. He stated the facility's policy was that oxygen tubing was stored in bags when not in use. He stated storage bags for oxygen should be checked daily and changed out weekly. He stated nursing staff was responsible for placing oxygen tubing storage bags in rooms where oxygen was being administered. He stated staff had been trained on proper storage of oxygen tubing by nursing administration. He stated his expectation of staff for proper oxygen tubing storage was that the tubing would be stored in a plastic bag when oxygen was not in use. The ADM stated a potential negative outcome for failure to properly store oxygen tubing would be infection control issues. During an interview on 12/09/24 at 11:27 AM with the DON, she stated she was not aware that residents requiring oxygen did not have storage bags for oxygen tubing. She stated she did not know what the facility policy stated regarding oxygen storage bags. She stated nurses and CNA's were responsible for placing oxygen tubing storage bags in rooms where oxygen was being administered. She stated her expectation of staff for proper oxygen tubing storage was to make sure tubing is stored properly and assure that tubing was not on the floor. She stated a potential negative outcome for failure to properly store oxygen tubing would be the risk of infection to residents. Record review of the facility-provided policy titled, Departmental (Respiratory Therapy- Prevention of Infection, Revised November, 2011 revealed: Purpose The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Steps in the Procedure Infection Control Considerations Related to Oxygen Administration . 8. Keep the oxygen cannulae and tubing used PRN in a plastic bag when not in use.

Based on observation, interview, and record review, the facility failed to provide food that was palatable, and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 meal reviewed for palatability. 1) The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical Soft, and Puree) at 1 of 1 meal observed (12/03/24 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During confidential individual interviews 5 of 14 residents voiced concerns related to food palatability. The residents stated the food did not taste good and the residents did not like eating the facility food. One resident stated she wasn't sure if the cooks knew how to follow a recipe. One resident stated the food was very bland with no taste. On 12/03/24 at 10:50 AM the Dietary Manager was informed of a request for a test tray for the noon meal. Observation on 12/03/24 at 1:07 PM the test trays arrived at the conference room and sampling began at 1:09 PM with the following results: Regular Meal - Regular Texture Enchiladas - no issues Spanish Rice - very bland, no taste Beans - thick/dry Churro - no issues Regular Meal - Mechanical Soft Texture Enchiladas - no issues Spanish Rice - bland, no taste Beans - thick/dry Regular Meal - Puree Enchiladas - no issues Spanish rice - bland, no taste, unappetizing look/lack of color Beans - no issues Interview on 12/03/24 at 1:20 PM, the DM was asked to try the test tray and stated the Spanish rice was a little dry and doesn't really have a flavor and the beans could have been more moist. The DM stated the rice comes in a pre-seasoned pack that she pours out of the bag and lets it cook in the oven. The DM stated she did not add any seasonings to the rice and residents have not complained to her before. The DM stated the beans also come in a bag and all she did was put them in a pot with water and let them cook. Interview on 12/09/24 at 9:34 AM, the DM stated some of the food items come in a pack with seasonings already and she is afraid to over-season the food. The DM stated salt and pepper packets are provided to the residents for extra seasonings if they want. The DM stated she tests food that comes out of the kitchen every now and then. The DM stated she was unaware of any complaints from the residents. The DM stated she has been trained on food palatability. The DM stated she did not know any negative outcomes to the residents because the residents always have alternate choices to choose from if they did not like the meal. Interview on 12/09/24 at 11:36 AM, the ADM stated the DM and the cooks are responsible for food palatability concerns. The ADM stated the dietary staff have been trained on food palatability and stated sometimes it may be a preference problem. The ADM stated all residents prefer different kinds of foods. The ADM stated the residents have a risk of weight-loss and not eating if the food did not taste good to them. Record review of the facility policy and procedure titled, Menu planning, with a revised date of 06/01/19, reflected the following: The facility believes that nutrition is an important part of maintaining the well-being and health of its residents and is committed to providing a menu that is well-balanced, nutritious, and meets the preferences of the resident population 43150

Based on observation, interview and record review, the facility failed to provide a private space for the resident's monthly Resident Council meetings for 13 of 13 anonymous residents who attended Resident Council meetings. (Resident Council 12/04/2024). The facility failed to provide a private place for residents to be able to hold Resident Council Meetings monthly. This failure could result in issues affecting the residents' feeling that their grievances are not being acted upon and could place all residents who attend the Resident Council meetings at risk for feelings of powerlessness and decreased self-worth. The Findings included: During the confidential Resident Council interview on 12/04/2024 at 9:45 AM. the thirteen residents in attendance stated they had no privacy during their meetings. The meeting space was arranged by the Activity Director and the meeting space was held in the front lobby. The front lobby had the front door, the Administrator's office, and the BOM's office. Even though there was a sign on the wall outside of the front door informing staff the Resident Council was meeting staff and visitors continued to enter the front door, Administrator's, and BOM's office. The residents stated that normally the resident council meeting is held in the dining room where all staff come and go through the duration of the meeting. The residents in the meeting stated it was communal area for staff to interrupt them during their monthly Resident Council meetings and they did not feel the meetings were private. The stated they would prefer the meetings to be private and only staff they invited be allowed to hear what they discussed. A total of seven observations were made of facility staff and visitors entering and exiting the front door, Administrator's office, the BOM's office, and coming in the front area from the facility during the confidential Resident Council interview on 12/04/2024. Observation of Resident Council Meeting on 12/4/2024 at 9:45 AM. The Activity Director had set up the meeting in the front lobby by the front door for 13 Residents to attend. Observed staff walking in and out during the meeting. Observed that the front lobby was next to the Administrator's office and the BOM's office. During an interview with the Activity Director on 12/06/2024 at 10:31 AM. The Activity Director stated she is responsible for setting up the resident council meetings and the place in which they are held. The Activity Director stated that the policy stated that the resident council meetings should be provided with privacy with no staff being able to interrupt the meetings. She stated that many of the residents had voiced their concern with staff members walking in and out of the meetings. She stated that the residents voiced their concern of the staff hearing what they were talking about and retaliating against them for it. The Activity Director stated that her biggest concern since she took the position is the privacy not being provided during resident council meetings. She stated that she had mentioned her concerns with the Administrator, and he had stated that she would need to get with the physical therapy team to see if that room could be used for the meetings. She stated that she was not sure why the meetings had not been moved to a private area for the residents. She had stated that she brought the privacy concern up to the Administrator twice and it had not been taken care of. The Activity Director stated that this had not been accommodated for the residents. She stated that the negative potential outcome of the residents not being provided privacy during resident council meetings is that the residents may get upset and feel that the staff will retaliate against them. During an interview with the Administrator on 12/09/2024 at 11:00 AM. The Administrator stated that the facility only has the physical therapy room that would accommodate the privacy for the meetings. The Administrator stated that the Activity Director had been told to get with physical therapy to see if the Resident Council meetings could be held in there. The Administrator stated that the negative outcome of not being able to provide privacy for the Resident Council meetings would cause the residents to not freely voice their concerns and to feel that their rights had been taken away. Record review of facility provided policy on 12/12/2024, titled, Resident Council, date revised in February 2021, stated: Policy Statement: The facility supports resident rights to organize and participate in the resident council. The purpose of the resident council is to provide a forum for: a. residents, families, and resident representative to have input in the operation of the facility. b. discussion of concerns and suggestions for improvement. c. consensus building and communication between residents and facility staff, and d. disseminating information and gathering feedback from interested residents. 2. All residents are eligible to participate in the resident council. The facility staff encourages residents who are willing to participate. Staff, visitors, or other guests may attend resident council meetings if invited by the respective resident group. 3. The resident council group is provided with space, privacy, and support to conduct meetings. 5. Council meetings are scheduled monthly or more frequently if requested by residents. The date, time, and location of the meetings are noted in the activities calendar. 6. A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the items of concern.

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 4 of 4 refrigerators reviewed for food safety (room [ROOM NUMBER], 122, 133, 142). The refrigerator located in room [ROOM NUMBER] did not have an up-to-date temperature log nor did it have a thermometer inside of the refrigerator. The refrigerator contained undated perishable food items. The refrigerator located in room [ROOM NUMBER] did not have a temperature log present nor did it have a thermometer inside of the refrigerator. The refrigerator contained undated perishable food items. The refrigerator located in room [ROOM NUMBER] did not have an up-to-date temperature log nor did it have a thermometer inside of the refrigerator. The refrigerator contained undated perishable food items. The refrigerator located in room [ROOM NUMBER] did not have an up-to-date temperature log nor did it have a thermometer inside of the refrigerator. The refrigerator contained undated perishable food items. These failures could place residents at risk for food borne illnesses. Findings included: Observation on 12/03/24 at 9:53 AM of personal refrigerator in room [ROOM NUMBER] revealed a temperature log, dated December 2024, with no temperatures recorded. Personal food items were noted in the refrigerator to include a creamy spinach dip and small squares of cheese. No thermometer was noted inside. Observation on 12/03/24 at 9:56 AM of the personal refrigerator in room [ROOM NUMBER] revealed no temperature log. An open bottle of iced tea with a label that read refrigerate after opening was observed in the refrigerator. No thermometer was located inside. Observation on 12/03/24 at 10:02 AM of the personal refrigerator in room [ROOM NUMBER] revealed a temperature log, dated November 2024, with no temperatures recorded. No December temperature log was observed. Personal food items were noted in the refrigerator to include potato salad, pimiento cheese, an open bottle of soda, an open container of cranberry juice, 3 containers of Jello and an open jar of pickles. No thermometer was noted inside. Observation on 12/03/24 at 10:09 AM of the personal refrigerator in room [ROOM NUMBER] revealed a temperature log, dated December 2024, with no temperatures recorded. No food items were noted in refrigerator at the time of observation. No thermometer was noted inside. Observation on 12/03/24 at 12:41 PM of the personal refrigerator in room [ROOM NUMBER] revealed a temperature log, dated December 2024, with no temperatures recorded. A partially eaten burrito wrapped in foil was observed inside. No thermometer was noted inside. Observation on 12/05/24 at 8:31 AM of the personal refrigerator in room [ROOM NUMBER] revealed a temperature log, dated November 2024, with no temperatures recorded. Personal food items noted in initial observation remained in the refrigerator to include potato salad, pimiento cheese, an open bottle of soda, an open container of cranberry juice, 3 containers of Jello and an open jar of pickles. No thermometer was noted inside. In an interview on 12/09/24 at 11:16 AM, the ADM stated he was not aware that personal refrigerator temperatures were not being monitored. He stated the maintenance supervisor was responsible for monitoring personal refrigerator temperatures, but he was no longer employed by the facility as of one week ago. The ADM stated personal refrigerator temperatures should be checked and logged daily. He stated, going forward, nursing would be responsible for checking food in personal refrigerators and monitoring daily temperatures. He stated his expectation of staff was to monitor personal refrigerators and report any concerns. The ADM stated a potential negative outcome for failure to monitor temperatures in personal refrigerators was that residents could become ill. In an interview on 12/09/24 at 11:27 AM, the DON stated she was not aware that personal refrigerator temperatures were not being monitored. She stated she was not sure what the policy was for monitoring personal refrigerators. The DON stated she would get with the ADM to establish whose responsibility it was to monitor personal refrigerators, but she assumed it was the responsibility of housekeeping. She stated personal refrigerator temperatures should be checked daily and followed up on. The DON stated a potential negative outcome for failure to properly monitor personal refrigerator temperatures was that the residents could get bacteria in the GI tract and it could be a health issue. Record review of the facility-provided policy titled, Food Receiving and Storage, Revised November 2022 revealed: Policy Statement Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation . 7. Residents may consume foods from sources not procured by the facility (e.g., food brought from family or visitors). . Foods and Snacks Kept on Nursing Units or in Resident rooms 1. All food items to be kept at or below 41 degrees F are placed in the refrigerator located at the nurses' station and labeled with a use by date. . 3. Refrigerators must have working thermometers and are monitored for temperature according to state-specific guidelines. Temperatures must be monitored. 4. Beverages are dated when opened and discarded after twenty-four (24) hours. 5. Other opened containers are dated and sealed or covered during storage. 6. Partially eaten food is not kept in the refrigerator.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. 1) The facility failed to keep refrigerator handles clean 2) The facility failed to properly store a cupcake pan. 3) The facility failed to properly store food in the pantry and refrigerator. These failures could place residents at risk for food contamination and foodborne illness. The findings included: Observation during a kitchen tour on 12/03/24 beginning at 9:20 AM revealed 5 fridge handles that had dry, sticky substances on the inside handle, a cupcake pan stored on the bottom shelf right side up and 1 bag of enriched farina hot cereal, opened date of 12/02/24, observed in a bag that was not fully sealed in the pantry. Interview on 12/03/24 at 9:29 AM, the DM stated she did not know why the refrigerator handles were not clean and stated the refrigerators are cleaned every Sunday. The DM stated the food should be stored fully sealed in the kitchen and stated the bag of enriched farina hot cereal was probably open because she used it earlier that morning. The DM stated the cupcake pan should be stored upside down. Observation on 12/05/24 at 11:09 AM during a return visit to the kitchen revealed a bag of shredded lettuce, open date of 12/02/24, not fully sealed in the refrigerator. Interview on 12/05/24 at 11:10 AM, Dietary Aide B stated she did not know why the bag of lettuce was not fully sealed in the refrigerator. Dietary Aide B stated all foods should be stored fully sealed in the refrigerator, but sometime bags open if they have too much air in them. Dietary Aide B stated she has been trained on properly storing food in the kitchen. Dietary Aide B stated the residents have a risk of cross contamination with food not being sealed all the way when stored. Interview on 12/09/24 at 9:34 AM, the DM stated that she is mainly responsible for ensuring kitchen foods and items are stored properly and kitchen items are cleaned. The DM stated the dietary staff have been trained on food storage and kitchen cleanliness. The DM stated the residents could possibly get sick due to food items not being properly stored, the refrigerator handles not being clean or the pans not being stored properly. Record review of the facility's policy and procedure title, Food Storage with a revised date of 2006, reflected the following: Food storage areas shall be maintained in a clean, safe, and sanitary condition. Policy Interpretation and Implementation: 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. 2. Food Service staff will store food or food items not requiring refrigeration .on shelves, racks, dollies or other surfaces .not subject to sewage or wastewater backflow or contamination by condensation, leakage, rodents, or vermin. All package food, canned foods, or food items stored will be kept clean and dry at all times Record review of the facility's policy and procedure titled, General Kitchen Sanitation dated 12/01/11, reflected the following: Policy: .The following guidelines should be used to ensure adequate sanitation practices are in place. Guidelines: 5. After cleaning and until use, all food-contact surfaces of equipment and multi-use utensils are stored and handled in a manner that protects the surfaces from manual contact, splash, dust, dirt, and food particles and otherwise in a clean and sanitary condition. 6. Non-food-contact surfaces of equipment are cleaned at intervals necessary to keep them free from dust, dirt, and food particles and otherwise in a clean and sanitary condition

Based on interviews, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 1 of 1 resident (Resident #51). The facility failed to ensure 1 of 1 resident were provided a copy of the grievance that Resident #51 had filed, upon request, Resident #51 had the right to obtain a written decision related to their grievance. This failure could place the residents at risk of unresolved grievances, decreased quality of life, and feeling of hopelessness. Findings included: Resident #51: Resident #51: Record review of Resident #51 face sheet revealed an admitted [DATE] with a BIMS (Brief Interview for Mental Status) of thirteen, meaning that Resident #51's cognition is intact. Resident #51 had a diagnosis that included: acute respiratory failure (cannot maintain normal levels of oxygen and carbon dioxide in the blood), pain in the left wrist, morbid obesity, major depression disorder, dysthymic disorder (mild but long term form of depression), heredity & idiopathic neuropathy (sensory and motor nerves of the peripheral nervous system are affected and no underlying etiology is found), high blood pressure, gout (form of arthritis that causes severe pain, swelling, redness and tenderness in the joints), osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down), muscle weakness, rotator cuff tear or rupture (a tear in the tissues connecting muscle to bone (tendons) around the shoulder joints), mass and lump in lower limb, edema (swelling). During an interview with Resident #51 on 12/05/2024 at 2:12 PM. Resident #51 stated that he had asked the Social Worker for a copy of the grievance that he had filed, and she stated that the Administrator told her to not give him a copy. Resident #51 was frustrated and stated, I would like to know what they are doing with the grievance that I filed. This grievance was an individual grievance filed by the resident. During an interview with the Social Worker on 12/09/2024 at 10:29 AM. The Social Worker stated that when Resident #51 had asked her for a copy of his grievances, she had asked the Administrator. She stated the Administrator stated the resident does not get a copy, so she told the resident that they do not give a copy. The Social Worker stated that she was not sure what the policy stated about giving a copy of grievances to the resident. The Social Worker read the policy in front of Surveyor. Social Worker stated that the policy stated that a copy should be provided to the resident. There was no resolution listed to the grievance. The Social Worker stated that the negative potential outcome of not providing a copy of the grievances would be that it may make the resident upset and it is impeding on resident rights. During an interview with the Administrator on 12/09/2024 at 11:00 AM. The Administrator stated that he does not know what the policy stated about providing a copy, but he is sure that he does not have to provide one. The Administrator read the policy in front of Surveyor. The Administrator stated that he did not realize that he had to provide a copy of the grievances, but he did see in the policy where he was supposed to provide a copy of the grievances. The Administrator stated that he had never had to give a copy of the grievances to a resident. The Administrator stated that the policy stated that he should provide a copy of the grievances to the resident. The Administrator stated that the negative potential outcome of not providing a copy of the grievance to a resident could make the resident feel as though the grievances are not being taken care of or addressed. The Administrator stated that it is a Resident Rights issue. The Administrator stated that it is the responsibility of the Administrator or the Social Worker to provide a copy of the grievances to the resident. Record review of facility provided policy on 12/5/2024, titled, Filing Grievances/Complaints, date revised in December 2004, stated: Policy Statement: Our facility will assist residents, their representatives (sponsors), other interested family members, or resident advocates in filing grievances or complaints when such requests are made. 1. Any resident, his or her representative (sponsor), family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, theft of property, etc., without fear of threat or reprisal in any form. 3. Grievances and or complaints may be submitted orally or in writing. Written complaints or grievances must be signed by the resident or the person filing the grievance or complaint on behalf of the resident. 4. The Administrator has been delegated as the Grievance Official for the facility. 5. Upon receipt of a written grievance and/or complaint, the social worker will investigate the allegations and submit a written report of such findings to the administrator within three working days of receiving the grievance and/or complaint. 6. The Administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need to be taken. 7. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. Such report will be made orally by the administrator, or his or her designee, within three working days of the filing of the grievance or complaint with the facility. A written summary of the report will also be provided to the resident, and a copy will be filed in the business office.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 2 (Resident #1 and Resident #61) of 3 residents and 1 (LVN A) of 2 staff reviewed for infection control. LVN A failed to perform hand hygiene between glove changes while providing wound care for Resident #1. LVN A failed to perform hand hygiene following a wound care procedure for Resident #1. LVN A failed to perform hand hygiene between glove changes while providing wound care for Resident #61. These failures could place residents at risk for spread of infection and cross contamination. Findings included: Resident #1 Record review of face sheet for Resident #1 revealed an [AGE] year-old male admitted to the facility 02/18/22 with the following diagnoses: Senile Degeneration of Brain (mental deterioration associated with advanced age), Dysphagia (difficulty swallowing), Depression, Anxiety Disorder, Hypertension (high blood pressure), Peripheral Vascular Disease (reduced blood flow to the limbs), Atherosclerotic Heart Disease (disease of the heart's major vessels), Chronic Obstructive Pulmonary Disease (airflow blockage and breathing-related problems), Heart Failure (heart condition), Kidney Failure (condition causing kidneys to not function properly ), Gastroesophageal Reflux Disease (digestive condition). Record review of Resident #1's current Physician's orders dated 12/09/24 revealed an order for daily wound care to right lower leg. Record review of Resident #1's annual MDS dated [DATE] revealed no BIMS was conducted due to the resident was rarely or never understood. Section M - Skin Conditions revealed Resident #1 was at risk for developing pressure ulcers and received pressure ulcer/injury care. Record review of Resident #1's Comprehensive Care Plan, revised on 08/15/24 revealed the resident was at risk for skin breakdown with approaches to follow skin care protocol and perform weekly skin assessments. On 12/06/24 at 10:03 AM, observed LVN A perform wound care to Resident #1's right lower leg. LVN A sanitized her hands and put on gloves prior to starting wound care. LVN A removed the wound dressing to the right lower leg, then changed her gloves. LVN A put on new gloves and performed care to Resident #1's right lower leg wound, per physician's orders. LVN A then changed gloves and placed a dressing to the right lower leg wound, per physician's orders. LVN A did not perform hand hygiene between glove changes. LVN A repositioned Resident #1 and exited the room. LVN A did not sanitize her hands prior to leaving the room or upon exiting the room. Resident #61 Record review of face sheet for Resident #61 revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Multiple Sclerosis (disease of the central nervous system), Asthma (narrowed airways), Unspecified Pain, Muscle Spasm, Arthropathy (disease of the joints), Major Depressive Disorder (persistently low mood), Anxiety Disorder (excessive fear or worry), Gastroesophageal Reflux Disease (digestive condition). Record review of Resident #61's current Physician's orders dated 12/09/24 revealed an order for daily wound care to left heel. Record review of Resident #61's Significant Change MDS dated [DATE] revealed a BIMS of 15, indicating the resident was cognitively intact. Section M - Skin Conditions revealed Resident #61 was at risk for developing pressure ulcers and received pressure ulcer/injury care. Record review of Resident #61's Comprehensive Care Plan, revised on 08/15/24 revealed the resident was at risk for skin breakdown with approaches to follow skin care protocol and perform weekly skin assessments. On 12/06/24 at 10:42 AM, observed LVN A perform wound care to Resident #61's left heel. LVN A sanitized her hands and put on gloves prior to starting wound care. LVN A removed the left heel wound dressing then changed her gloves. LVN A put on new gloves and performed care to Resident #61's left heel wound, per physician's orders. LVN A then changed her gloves and placed a dressing to the left heel wound, per physician's orders. LVN A did not perform hand hygiene between glove changes. LVN A cleansed her hands with soap and water prior to exiting the room. During an interview on 12/06/24 at 10:53 AM with LVN A, she stated she did not sanitize her hands between glove changes while performing wound care for Resident #1 and Resident #61. She stated she did not sanitize her hands after performing wound care for Resident #1. LVN A stated she should have used hand sanitizer or washed her hands between glove changes and after performing wound care. She stated her failure to properly sanitize her hands during and after wound care was just an oversight. LVN A stated she had been trained at the facility on proper hand hygiene by the DON. She stated hand hygiene training occurred approximately once per month. LVN A stated a potential negative outcome for failure to properly sanitize hands during and after wound care would be infection and cross contamination. During an interview on 12/09/24 at 11:16 AM with the ADM, he stated he was not aware that staff failed to observe proper hand hygiene during and after wound care. He stated the facility policy was to follow hand hygiene protocol at all times. He stated hands should be sanitized between glove changes. He stated hands should be washed prior to exiting the room after performing wound care. The ADM stated nursing administration was responsible for training staff on proper hand hygiene. He stated his expectation of staff for proper hand hygiene during and after wound care was that staff practice proper hygiene per protocol during all care. The ADM stated a potential negative outcome for failure to observe proper hand hygiene was infection control issues. During an interview on 12/09/24 at 11:27 AM with the DON, she stated she was not aware that staff failed to observe proper hand hygiene during and after wound care. She stated the facility's policy for hand hygiene during and after wound care was that hands were sanitized prior to beginning the procedure and with each glove change, before putting on clean gloves. She stated hands should be washed prior to exiting the room and after performing wound care. The DON stated staff were trained on proper hand hygiene regularly by nursing administration and skills checks were done annually for staff on proper hand hygiene practices. She stated her expectation of staff for proper hand hygiene during and after wound care was that staff practice proper hygiene according to facility-provided education as well as their nursing education. The DON stated a potential negative outcome for failure to observe proper hand hygiene was cross contamination and infection. Record review of the facility-provided policy titled Handwashing/Hand Hygiene; Revised October 2023 revealed: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. . Indications for Hand Hygiene 1. Hand hygiene is indicated: immediately before touching a resident; . d. after touching a resident . f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal. 5. The use of gloves does not replace hand washing/hand hygiene.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly for 2 of 2 medication carts (Station 1 medication cart, and Station 2 medication cart), reviewed for medication storage. 1. The medication cart assigned to Station 1 had loose pills. 2. The medication cart assigned to Station 2 had loose pills. This failure could place residents at risk of not receiving prescribed medications as ordered and drug diversions. The findings included: 1. On 12/03/24 at 5:44 PM an observation of the medication cart for Station 1 was made with MA A. Three loose pills were found in the medication cart drawer. MA A placed the loose medications in a dispensing cup and the ADM identified the medications as Carbidopa/Levodopa 25-100 (1/2 tablet), Carbamazepine 200 mg (1 tablet) and Xarelto 200 mg (1 tablet). MA A and LVN B destroyed the loose medications in the sharps container and documented the destruction in the electronic record. During an interview on 12/09/24 at 11:23 AM with MA A, she stated there should not be loose medications on the medication cart. She stated she was not sure why there were loose medications on the cart. MA A stated it was her responsibility to check the cart for loose medications before her shift. She stated carts were usually checked once per week for proper storage and cleanliness. MA A stated carts were also audited each month by the pharmacy consultant. She stated she had received training by nursing administration on proper medication storage. MA A stated a potential negative outcome of loose medications on the medication cart would be that the resident may miss the dose of medication. 2. On 12/03/24 at 6:42 PM an observation of the medication cart for Station 2 was made with MA B. Five loose pills were found in the medication cart drawer. MA B placed the loose medications in a dispensing cup and the ADM identified the medications as Levothyroxine 75 mg (1 tab), Ondansetron HCl 4 mg (1 tablet), Gabapentin 300 mg (1 capsule), and Eliquis 2.5 mg (1 tablet) .MA B and LVN B destroyed the loose medications in the sharps container and documented the destruction in the electronic record. During an interview on 12/03/24 at 8:24 PM with MA B, she stated there should not be loose medications on the medication cart. She stated she assumed the medications had been dropped or fell out of the blister packs. MA B stated it was her responsibility to check the cart for loose medications before her shift. She stated carts were usually checked for loose or expired medications and were cleaned every Sunday. She stated she had received training in school and by nursing administration on proper medication storage. MA B stated a potential negative outcome of loose medications on the medication cart would be missed medication doses. During an interview on 12/09/24 at 11:16 AM, the ADM stated he was not aware there were loose medications on the cart. He stated the policy for proper medication storage is that medications on the cart are secured and the carts were checked daily for loose or expired medications. The ADM stated his expectation of staff regarding proper medication storage is that medication aides and nursing staff properly monitor the medication carts and medication room for proper storage of all medications. The ADM stated a potential negative outcome of loose medications on the medication cart would be missed medication doses or wrong medications given. During an interview on 12/09/24 at 11:27 AM, the DON stated she was not aware that there were loose medications on the medication cart. She stated it was the responsibly of nursing administration to train staff on proper storage of medications on the cart. The DON stated the policy for proper monitoring of medication storage was that carts were checked daily for loose medications. She stated the consultant pharmacist would conduct cart audits during monthly visits to check for proper medication storage. She stated training was conducted through in services and spot checks of medication carts conducted by nursing administration. She stated it was her expectation of staff to check medication carts thoroughly each day for loose medications. The DON stated a potential negative outcome of loose medications on the cart would be that medications were not stored safely and may not be able to be properly identified and that residents may miss doses of medication. Record review of facility provided policy labeled, Storage of Medications, revised November 2020, revealed: Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: . 2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medication between containers. 3. The nursing staff is responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner.

Based on observation, interview and record review, the facility failed to ensure each resident receives adequate supervision to prevent elopement for 1 of 7 residents who wandered (Resident #60). The facility further failed to ensure that the resident environment remained as free of accident hazards on 2 of 2 Halls (Hall1/Central and Hall2), in that: 1). The facility failed to adequately supervise Resident #60 to prevent him from eloping from the facility on 8/18/22 and 9/03/22. The facility failed to develop and implement interventions to prevent elopement after multiple verbalizations by Resident #60 of wanting to leave the facility which resulted in him eloping. 2) The facility failed to store chemicals in a safe manner and were left accessible to residents in common areas on 2 of 2 Halls (Hall 1/Central and Hall 2). An immediate jeopardy (IJ) was identified on 9/28/22 at 5:25 PM. While the IJ was removed, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy and a scope of pattern. These failures related to adequate supervision could place residents at risk for wandering into unsafe environments outside of the facility and sustaining serious injury, harm, impairment or death. Failures related to chemical storage could place residents at risk for chemical injuries. The findings include: 1) Resident #60 Record review of the face sheet and Order Summary Report for male Resident #60 dated 9/15/22 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnosis of [CONDITION(S)], Unspecified, Major Depressive Disorder, Recurrent, Unspecified, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Muscle Weakness (Generalized), Cognitive Communication Deficit, Unsteadiness on Feet, Major Depressive Disorder, Recurrent Severe Without Psychotic Features, and Anxiety Disorder Due to Known Physiological Condition. Record review of the admission MDS assessment for Resident #60 dated 8/19/22 revealed that the resident had a BIMS score of 4 , indicating he was cognitively impaired. Further record review of the MDS revealed the resident had a behavior of rejecting care. This behavior occurred every one to three days. The resident was also documented as wandering and this behavior occurred daily. It was further documented that the residents wandering did not place the resident at significant risk of getting to a potentially dangerous place, such as stairs, outside of the facility. Record review of the current undated care plan for Resident #60 revealed that there was a Focus titled, The resident is an elopement risk r/t dementia. ***Patient has a (electronic monitoring device) *** *(Electronic monitoring device) checks 3 times each shift. *Staff will round to lay eyes on patient every 1 to 2 hours and as needed. Patient eloped on 08/18/2022* WAS FOUND SAFE AND RETURNED TO BUILDING Date Initiated: 08/10/2022 Revision on: 08/19/2022. The documented Goal for this Focus was documented as follows, The resident's safety will be maintained through the review date. Date Initiated: 08/10/2022 Revision on: 09/07/2022. Target Date: 11/30/2022. o The resident will not leave facility unattended through the review date. Date Initiated: 08/10/2022 Revision on: 09/07/2022 Target Date: 11/30/2022. The Approach for this Focus was documented as, o Assess for fall risk. Date Initiated: 08/10/2022 o Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: Date Initiated: 08/10/2022 . Record review of the Elopement Risk Assessment for Resident #60 conducted on 8/09/22 by LVN D revealed that the resident made statements and or threats to leave the facility and made frequent request to go home. It also documented that the resident had confused expressions related to tasks to complete. It further documented that the resident verbalized anger and frustration related to his placement. The document stated that the resident had restless behavior such as wandering. Additional information listed on the form revealed that the resident did not recognize stoplights and signs, did not know precautions when crossing streets and did not know the location of his current residence. It was further documented that the resident does not recognize all needs but some. Related to physical capacity it documented that the resident ambulates independently or with device. Cognitive skills for daily decision-making were listed as modified independence - some difficulty in new situation only. Record review of the Progress Notes (8/10/22 thru 9/03/22) for Resident #60 revealed: -On 8/18/22 at 4:45 PM the resident could not be found in the facility. He was found and returned to the facility at 6:37 PM. The nurse on duty was LVN C (agency). The police were called, and facility staff searched for the resident in the facility and surrounding areas. Family and department heads were informed. On his return it was determined he had no injury and an electronic monitoring device was placed on the resident on his return. -On 8/28/22 the resident removed his electronic monitoring device and staff placed another one on his ankle. -On 8/30/22 the resident's wife discovered his electronic monitoring device amongst the resident's possessions and staff placed another one on the resident's right wrist. -On 9/3/22 at 9:15 AM Resident #60 could not be found in the facility again. He was found by family at 11:43 AM and returned to the facility at 12:00 PM. The LVN on duty was LVN D (agency). The police were called, and facility staff searched for the resident in the facility and surrounding areas. Family and department heads were informed. The resident had no injuries. -On 9/03/22, 12:00 PM - Upon entrance to facility, door alarm sounded d/t resident being noted to have electronic monitoring device on wrist. How resident got out of facility with electronic monitoring device on is TBD ADON requested Q 30 min checks for a couple areas then hrly (hourly) until further notice . The resident was discharged from the facility on 9/03/22. Record review of the Incident-by-Incident Type list for the facility dated 9/13/22 revealed that there was one resident listed as having an elopement incident. The date range for the list was 3/13/22 to 9/13/22. Resident #60 was not listed on this document as eloping from the facility. Record review of the MAR/TAR for Resident #60 for August 2022 revealed that the facility started ordered electronic monitoring device checks on 8/11/22 on the night shift. The electronic monitoring device was checked Q shift. On 8/17/22 there was no documentation that the electronic monitoring device was checked on the dayshift. On 8/18/22 it was documented that the resident had his electronic monitoring device on during the day and night shift. On 8/19/22 at 4:00 PM the residents electronic monitoring device monitoring order changed from Q shift to Q4 hours. Further documentation on the TAR revealed that on 8/25/22 there was no documentation that the electronic monitoring device had been checked at (4:00 AM). The resident's electronic monitoring device was documented as being off him on the following dates and times: 8/28/22 at (8:00 PM) 8/30/22 at (4:00 PM and 8:00PM) 8/31/22 at (12:00 AM and 8:00 AM) On 8/31/22 there was no documentation of the electronic monitoring device being checked at (4:00 AM). Record review of the September 2022 MAR/TAR for Resident #60 revealed an order for electronic monitoring device checks Q4 hours. There was no documentation on 9/1/22 at (4:00 PM) that the electronic monitoring device was checked. Further record review of this MAR/TAR for Resident #60 revealed that the electronic monitoring device documentation for his right ankle and left wrist on 9/2/22 ( 8:00 AM and 12:00 PM) was documented as Other and to see the nurses notes for an explanation. The resident was documented as having the electronic monitoring device on starting 9/02/22 at (4:00 PM) through (12:00 PM) on 9/3/22. The electronic monitoring device checks on 9/03/22 revealed that the resident had his electronic monitoring device on for the 8:00 AM and 12:00 PM checks. Record review of the Progress Notes for Resident #60 revealed no documentation as to why there was no on or off electronic monitoring device documentation on 9/2/22 at (8:00 AM) and (12:00 PM). On 9/16/22 at 10:11 AM, an interview and record review was conducted with LVN C (agency) regarding Resident #60's wandering and eloping from the facility. He stated the resident was a wanderer but could converse and state his needs. He added that he would hang around at the exit door near room 108. He was definitely a wanderer. Regarding the day the resident eloped, he stated, on 8/18/22 it was a normal day. Dinner was served. LVN C was in the dining room helping out. Staff report to him at approximately 4:45 PM that they could not find the resident. LVN C searched every room, outside and surrounding areas including businesses. He also called local hospital ERs. Family and law enforcement were called, and the resident was located by police at 82nd street and returned at approximately 6:50 PM. Upon the resident's return, he was assessed, and an electronic monitoring device was placed on him. He further stated the resident had a history of asking for scissors to cut off his electronic monitoring device. The LVN stated he was on duty the next day and monitored him closely. He added he double checked him every hour or two for his whereabouts. There were no other interventions to prevent him from eloping. The LVN stated he was told by staff the resident would remove his electronic monitoring device and ask for scissors to cut it off. He added that the resident never asked him for scissors. LVN C was then asked about their procedures related to electronic monitoring devices. He stated he visually checked the electronic monitoring devices and documented it in the MAR. He added that if a resident wanders to the front of the facility, the electronic monitoring device alarms. He added staff used harder zip type ties to keep the electronic monitoring device on once they knew he could take it off. LVN C then checked the electronic incident documentation system to see if an incident report had been developed for the elopements on 8/18/22 and 9/03/22 and found none. LVN C also stated that he contacted the Administrator, DON and ADON about the 8/18/22 elopement but did not contact the physician. He added that it was not OK not to inform the physician. Regarding the missing incident reports, he stated if there is no documentation it is not done. He further stated he was not sure if the facility had an elopement protocol and did not know what the facility elopement protocol was. He stated, I'm just agency. He also added that there was no documentation of his monitoring of the resident every one or two hours. He stated that his monitoring documentation was only in the nurses' notes . On 9/16/22 at 11:14 AM, an interview was conducted with the DON. Regarding Resident #60 she stated he was tall, had dementia, confusion, was a wanderer and was admitted from a secure facility . Regarding wandering intervention for the resident, she stated after the first elopement they increased electronic monitoring device checks and checked the room daily. Staff checked every shift and more often. The second time he eloped, staff implemented checks every 2 hours. She added, the last time he eloped, he still had his electronic monitoring device on. Staff did not know if someone let him out. She was unsure how far he was from the facility the first time he eloped. The second time he eloped he was found outside a new restaurant on 82nd street. Regarding their elopement protocol, she stated nurses are to check each room. Some staff checked the parameters. Within an hour we called the police. Regarding any orientation provided to agency nurses prior to assuming duties in the facility, she stated, staff conduct a quick one. Staff familiarize them with the charting system. Contact information is given to them for the DON and ADON. Regarding residents, agency staff know what to do. They are informed of resident tendencies. On 9/16/22 at 11:29 AM, an interview was conducted with the Administrator. Regarding elopement protocols, she stated, if residents are not found they look in-house. The administrator is informed, and the administrator informs staff by group text and the department heads look for the resident. She stated the second elopement was handled this same way. Regarding Resident #60 she stated, he was a dementia resident admitted from a secure nursing home. He did not do any wandering there. He was here two weeks and then was found outside. He was gone about 45 minutes . He was not exit seeking. She added that after meals his dementia tells him to go to work. Staff knew to monitor him after meals. He thought he was trying to get to work when he was found at a restaurant on 82nd and Quaker Avenue (Approximately 0.6 miles from the facility). He was found quickly. She believed, the first time he was found on 76th and Salem Avenue (approximately 0.3 miles from the facility). She further stated, both times he was gone an hour or less . The second time was on a Saturday. On 9/16/22 at 11:54 AM, an interview was conducted with the Maintenance Supervisor regarding the electronic monitoring device system. He stated there are two doors with the electronic monitoring device system; the front and the dining room that are exits are alarmed. He added he checks the doors weekly on Mondays. During the generator test it deactivates the electronic monitoring device system and the test lasts 30 minutes . He further stated to test the electronic monitoring devices, he uses an electronic monitoring device and goes to the door to check if it alarms. He also stated that he has a resident, with a monitoring device, go by the door and see if it locks. Regarding Resident #60, he stated the resident got out two times. The first time, staff say he cut off the electronic monitoring device. The second time only thing he could think of was the resident went out with a visitor. He added he did not know if anyone heard the electronic monitoring device alarm go off, but staff should have. Record review of the facility documentation on Door Alarm checks revealed that weekly checks were made. Between 8/01/22 and 9/12/22 all door alarms were documented as passing and had no issues (8/01/22, 8/08/22, 8/15/22, 8/23/22, 8/29/22, 9/05/22 and 9/12/22). On 9/16/22 at 12:45 PM, an interview was conducted with the ADON regarding Resident #60's elopement. Regarding why the incidents happened, she stated, some family may have let him out. He may have been gone out before staff saw him. It's hit and miss who's around the exit door. LVN D told her she did not hear an alarm. Agency staff was at station one. She added that the first elopement he said he was going to work. It was something all staff knew. These were suggestions of what he was thinking. She stated they ensured residents do not elope outside of the facility by conducting hourly checks , frequent checks. She added if staff hear the alarm, they go straight to the door. She further stated there were no documentation of the (hourly) checks. She added, staff make sure they make rounds. She stated, everyone is responsible to ensure that residents do not elope from the facility. She added, she expected that staff are in the building working and others are out searching for any eloped residents. She stated that if residents were not appropriately monitored and eloped, others could elope from the facility. She also stated that there was no paper documentation of the monitoring that they conducted on Resident #60. On 9/16/22 at 2:40 PM, an interview was conducted with the Administrator. Regarding Resident #60 elopements she stated, the staff did not think he would leave prior to the first elopement . She added that staff were supposed to monitor the resident after dinner . She also stated that someone may have let him out. She stated caregivers, charge nurse, nursing and administrator were responsible for ensuring that residents do not elope from the facility. She added she expected staff to provide a better monitoring system to prevent elopements. She further stated she made it clear to staff and they should have taken Resident #60 to his room after his meals. She was asked how an elopement could affect residents. She responded by stating that the facility makes sure residents are in a safe environment, experiencing no harm. On 9/16/22 at 3:06 PM, an interview was conducted with agency LVN E (agency). She stated she worked in the facility approximately three times a month. She stated that she was not oriented by the facility regarding missing residents and the elopement protocol prior to working in the facility. She stated that she had been oriented at other facilities. She stated if residents elope from the facility they could be in danger, run over, or multiple things happen to them. On 9/19/22 at 7:50 PM an interview was conducted with LVN D (agency at the time of elopement). She stated Resident #60, was a roamer and walked all day and night. He was super confused. Sometimes he would layer his clothes wearing seven or eight shirts at a time. All day he would say he was going somewhere. She stated she was not told specifically to take the resident back to his room after meals, but felt it was a given fact. Regarding the 9/03/22 elopement, she stated, it was an hour and a half after breakfast . She had been looking for him for him for something and then discovered he was missing. She added staff started checking and he was not found. Staff did not hear an alarm; no one did. She stated, if the door is held, it should have alarmed. She added that she did not know what exit he may have gotten out of. She stated she did not develop an incident report but documented the incident in the nurse's notes. She stated the incident occurred on her second day at work and she called the family, ADON and DON. She added that family brought the resident back and she assessed him. She was asked what could result from an elopement of a resident. She stated if residents were to elope from the facility they could be hit by a car and be led to do things they should not do. She added that the resident talked well and presented himself well if you were not aware he had dementia . She stated that she had not call the doctor about the incident. She stated when she started working in the facility, nothing special was told to her about Resident #60, but she was made aware that he removed his electronic monitoring device. She added that she placed it back on him a couple of times and that he would pull real hard and could pull it off. During an interview conducted on 09/29/2022 at 9:42 AM with the Administrator , she said she did not recall if they had reviewed camera footage once she was notified the facility had been searched, they started searching outside. She said she was out of town during Resident #60's second elopement. She said it was her understanding that both elopements were through the front door of the facility. She was not sure if an alarm went off, she was told Resident #60 was out on the porch outside of the facility, seen by another visitor, then later found at a restaurant. She said the first time Resident #60 eloped; he was found about a block from his house, which she said was in the area of the facility, talking to the neighbors who called the police while they were at the facility with the Administrator. She further stated the electronic monitoring device alarm on the door goes off until the keypad code is entered by staff. Observation made on 09/28/2022 at 8:16 AM showed a camera to be in the lobby facing the entrance to the facility. Observation made on 09/28/2022 at 8:45 AM showed a camera facing the first nurses' desk nearest the entrance to the facility (Hall1). Observation on 09/28/2022 at 8:47 AM showed a camera facing the facility's dining hall and back door entrance. Observation made on 09/28/2022 at 8:48 AM showed a camera facing the break room. Observation made on 09/28/2022 at 8:50 AM showed a camera facing the south side door at the end of the east hall (Hall 2). Observation made on 09/28/2022 at 8:35 AM showed a camera to be facing the north side door at the end of the east hall (Hall 2). During an interview conducted on 09/28/2022 at 8:59 AM with the Administrator, she said all the cameras were working. She said the monitors were in the central supply room in the beauty shop. During an observation and interview on 9/28/22 at 9:58 AM with the Maintenance Supervisor, he was asked if it would be possible to check camera footage from specific dates. He was not sure if the cameras saved footage. Observation of the central supply closet inside the beauty salon room with the Maintenance Supervisor revealed a monitor could be seen with several viewing panels for all cameras showing no footage being taken currently on any camera as indicated by a blank black screen. Using the search feature found on the monitor, the Maintenance Supervisor typed in the dates in question (08/18/2022, 09/03/2022) and no footage was found. Observation of the cameras in the Dietary Manager's office showed live footage from only the temperature-scanning camera located in the lobby could be seen. He was unable to show footage of the dates in question (08/18/2022, 09/03/2022). During an interview conducted on 09/28/2022 at 9:28 AM with the DON. When asked about the cameras and whether they had ever reviewed camera footage after Resident #60's elopements. She said she did not know how to access them and has never reviewed camera footage. During an interview conducted on 09/28/2022 at 10:33 AM, the Maintenance Supervisor stated he had spoken with the facility's IT (Information Technology) department and was told the cameras send footage to the Administrator's computer with storage only for the last 30 days. He said the Administrator did not know that though, and he was going to her office next to see if it was set up on her computer. Based on the time frames of stored footage, he was asked to provide footage from 09/03/2022 for the hours leading up to Resident #60's noted absence from the facility at 9:15 AM. During an interview conducted on 09/28/2022 at 11:36 AM with the Administrator, she said they had made progress on finding camera footage from 09/03/2022 and said: they are looking at it right now. During an interview conducted on 09/28/2022 at 11:37 AM, the ADON was asked if they had found the footage from 09/03/2022 pertaining to Resident #60 and the elopement from 09/03/2022. She said they were still looking. Observation made on 09/28/2022 at 11:37 AM showed staff members in the Business Office Manager's office looking at camera footage on the computer. During an interview conducted on 09/29/2022 at 10:39 AM with the Business Office Manager concerning footage that she and the ADON had reviewed the previous day, she said they were not able to see any footage of the resident exiting the building. She said they had reviewed footage from all the cameras in the facility yesterday, and that not all doors exiting the facility had a camera facing them that adequately captured the view of the door. On 9/28/22 at 9:10 AM, an interview was conducted LVN A. Regarding Resident #60 she stated, she remembered him. Staff were told to basically watch him and keep an eye on him; Every 30 minutes. She had to check his wander guard four times a day because he would take it off. His roommate was Resident #40. Their room was near the nurse's station. Regarding Resident #60's electronic monitoring device removal, she stated she did not know what he cut it off with. She never witnessed the removal. Staff placed a type of zip tie on it to keep it on. The band looked like it was cut when she saw it. She thought he may have got a butter knife to cut it off. She stated she never checked the resident for a knife and she only kind of looked around his room for an item that could have been used to cut it off. She added, he could get aggressive. She stated Resident #60 mostly watched TV. It seemed lunchtime he might get up. Regarding training about elopements and wandering residents she stated, she had not had any since being in the facility, which was approximately 2 months. She stated she learned from other facilities to keep an eye on them. The other places (facilities) staff saw them and where they were. Regarding any documentation of the 30-minute checks that she conducted on wandering residents, she stated she recently started documenting the checks and added that her weak point in nursing was documentation. She further stated, she could not recall staff asking her to document the one- or two-hour checks on Resident #60's whereabouts. Regarding any interventions told to her after the 8/18/22 elopement, she stated, she was told to make sure to keep an eye on him; her and the CNAs. He was always dressed and ready to go. He mainly stayed in his room. She further stated she never had anything to write on the nurse communication sheets about Resident #60. She stated the nurse communication sheets were placed in the box and then given to the ADON. Record review of the Nurse Communication Sheets for 8/18/22 and 9/03/22 - 9/04/22 revealed no documentation related to Resident #60. On 9/28/22 at 9:45 AM LVN A was interviewed and stated, sometimes Resident #60 ate in his room and she tried to be in the dining room to feed her residents during meals. She added, because he was an elopement risk, she kept her eyes on him. She further stated that no one had told her that Resident #60 needed to be taken to his room after meals. On 9/28/22 at 9:53 AM an interview was conducted with CNA I. She stated staff did one-hour checks on Resident #60 and documented it on their POC (CNA electronic resident documentation kiosk). Staff just checked that he had not wandered off and that his electronic monitoring device was on. He was known to take it off. She stated she never figured out how he got it off. He would tear it off. He was strong. Regarding the 8/18/22 elopement, she stated she was the one that noticed he was gone. Staff searched inside and outside. Staff would see him wandering. He walked with Resident #40. She noticed she had not seen him at her hourly check . It was at supper, and she had not seen him. After he returned, staff was instructed to conduct 30-minute checks. They changed where his wander guard was applied. She added, there was no documentation of the 30-minute checks, it was just every day and it continued. She stated, she received training regarding wandering residents and elopement weeks or months ago. She further stated staff were told Resident #60 should go back to his room after meals by LVN A. On 9/28/22 at 10:40 AM, an interview was conducted with the DON. Regarding interventions implemented after the elopement on 8/18/22, she stated, electronic monitoring devices were checked frequently, and redirection using activities. The nurse was to report abnormal behaviors. The nurse also made rounds. Staff were rounding different hours for the electronic monitoring devices. On 8/19/22 they checked the wander guard three times and then later every four hours. Regarding interventions for the resident removing his electronic monitoring device, she stated, place a new one on and provide education to the resident which was not very effective. Staff changed the positions of the electronic monitoring device. Staff made sure the electronic monitoring devices was comfortable. The main intervention was rounding every four hours. She stated that she would check him when she saw him. The Resident spent a lot of time in common areas. Regarding how he got the electronic monitoring devices off, she stated there was nothing in his room to remove it. Staff thought he was just pulling it off. The resident made comments about scissors. Staff checked everywhere they could for something he used to take the electronic monitoring devices off. The DON stated she thought it was irritating to him and he pulled it off. Regarding if staff had been instructed to take the resident to his room after meals, she stated, she instructed staff to conduct more rounding. She further stated she did not instruct staff to take Resident #60 back to his room after meals. Regarding in-services or training provided for wandering residents and elopements, she stated, staff were provided verbal education. She added more attention was given to station two since Resident #60 resided there. She stated she talked to LVN D, who was the charge nurse. LVN A and agency staff. She added she started the verbal education when the electronic monitoring device was placed on him. Regarding the screening process to determine if referred residents were appropriate for admission, she stated, they reviewed the referrals with a whole team. If there were unresolved issues with the referral, the DON was responsible for addressing the issues. She stated that she did not see Resident #60 prior to admission. She added that the referrals for admission for Resident #60 were received by the Administrator. The DON stated she ensured the nurses were competent in their skills in caring for residents that wandered by the DON and ADON talking to them. She added staff do rounds and check on the residents. Regarding what type of plan was in place for wanderers, she stated, the facility has electronic monitoring devices and an electronic monitoring device system. It locks the door. Staff check doors weekly. Staff try to provide activities for wanderers. Regarding any type of in-services provided on wanderers and elopement since admitting residents with those issues, she stated, staff were provided a lot of verbal instruction. The most recent documented in-service was 6/16/22. She stated, she did not think the facility was secure enough for Resident #60. She added that the facility was secure to a certain extent. On 9/28/22 at 11:24 AM an interview was conducted with the DON regarding why there was no incident report done for Resident #60's two elopements. She stated, no incident report was done since staff found him within two hours. She stated she was told that by the Administrator. During an interview conducted on 9/28/2022 at 1:47 PM with the DON , she was asked if notification to Resident #60's physician regarding his elopement had been made. She said that notification to the resident's physician would be documented in a progress note in the EMR (Electronic Medication Record). She said she would verify with the ADON as well and ask if there is anywhere else that would be documented. This documentation was never provided. During an observation and interview on 9/28/22 at 11:28 AM, CNA I demonstrated where the resident monitoring documentation was located in the POC system for CNAs. The dates range checked was 8/19/22 through 9/03/22. There was no documentation in this system of hourly monitoring checks. At this time CNA I stated, she guessed their instructions to monitor were just verbal. Staff were verbally told to do it. She confirmed that there was no documentation on any of those days that one hour or 30 minutes or any resident checks were conducted for Resident #60. The only documentation that she found was on 9/02/22. There was a note that stated, walk with supervision. On 9/28/22 at 11:45 AM an interview was conducted with the Administrator. Regarding monitoring documentation, she stated, staff would not be documenting unless he was one-on-one supervision or mandated. She stated, It was just known, especially after meals, that he wandered. There was nothing written. Regarding any viewing of the cameras footage for Resident #60's elopements. She stated, they cannot find anything on camera so far. Regarding in-services offered on wanderers and elopement, she stated there were no written in-services, but everyone was notified. She [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure that CNA #1 was able to demonstrate competency in skills and techniques necessary to care for resident #17 ' s needs as related to bed baths in that: a) CNA #1 Failed to use accepted/effective methods in dealing with an agitated resident who was blind, quadriplegic and dependent. CNA #1 was upset and used a loud voice while conducting a bed bath for resident #17. During the bed bath, resident #17 yelled the entire time, continuously, "you're hurting me!", "I'm pissed off!", cursing staff ([***] !) and making gestures with his arms and hands all while his face was red. CNA #1 did not stop the bath or ask for assistance from a nurse, etc., and b) CNA #1 did not use accepted bed bath method when washing and rinsing resident #17. During the bed bath CNA #1 used the same wash cloth on perineal and other body areas and finally rinsed the resident by pouring a bath basin filled with water all over him from upper chest to feet which soaked the bed/sheets. This problem could cause residents, requiring bed baths, not to be cleansed adequately and cause an increase in anxiety. This problem affected 1 of 2 residents who were assessed as requiring a bed bath (#17). This problem had the potential to affect both residents in the facility assessed as requiring bed baths. The findings include: 1. On 4-17-13 at 11:19 a.m., the door to Resident #17's room was closed and the resident's voice could be heard coming from the room saying "You're hurting me!" in a loud voice. The surveyor entered the room on 4-17-13 at 11:20 a.m., CNA #1 was observed giving resident #17 a bed bath, along with CNA #2 assisting. Resident #17 yelled repeatedly "I'm pissed off!" and cursed ("[***] "), as CNA#1 spoke to the resident in a loud voice and continued wiping the resident with a wet cloth. The resident's face was red as he yelled throughout the procedure. The resident exhibited some physical resistance to care by moving his arms and making gestures with his hands in a limited manner; no lower body resistance/movement was observed. CNA #2 held the resident's hand and talked to the resident in a normal/natural tone of voice. Resident #17's genital area was covered with a towel during this procedure. Towards the end of the bath, CNA #1 rinsed the resident's body by taking a bath basin filled with water and pouring it on the resident from upper chest to feet. This action soaked the bed and sheets. She also slammed the dresser drawer loudly, jerked the privacy curtain backwards/open rapidly and continued to speak in a loud tone of voice. In an additional observation of the resident revealed that resident #17 had a skull deformity and foot drop. Review of the April 2013 Physician order [REDACTED]. Observation of resident #17 on 4-18-13 at 8:15 a.m. revealed that he was in bed and had scars on his skull and could respond verbally to some questions with difficulty. It was also noted at this time that there was a sign on the wall stating "My name is (Resident #17) I AM BLIND. Please explain what you are doing so I am not scared." 2. Review of the most recent MDS Quarterly review dated 2-17-13 documented that the resident had "Adequate" hearing and "Highly Impaired" vision. Bathing Self-Performance was listed as "Total dependence." The MDS also documented Physical behavior symptoms directed toward others as occurring "4 to 6 days", Verbal behavioral symptoms directed toward others as occurring "1 to 3 days" and Other behavior symptoms not directed toward others as occurring "daily." The MDS documented Active [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] documented that the resident had "Adequate" hearing and "Highly Impaired" vision. Bathing Self-Performance was listed as "Total dependence." The MDS also documented Physical behavior symptoms directed toward others as not occurring, Verbal behavioral symptoms directed toward others as occurring "4 to 6 days" and Other behavior symptoms not directed toward others as occurring "daily." It was also documented that these behaviors "significantly interfere with the resident's care." The MDS documented Active [DIAGNOSES REDACTED]. Review of the current care plan dated 7-06-12 stated a problem as "I am legally blind d/t (due to) gunshot to head ..." Another Problem stated was I require assistance in making all daily decisions r/t (related to) [MEDICAL CONDITION]. Under Approaches for this problem it stated " ...Provide consistent direct care givers on all shifts ..." A Problem stated "I have impaired short and long term memory loss r/t [MEDICAL CONDITION]" The Approaches listed for this problem stated "Provide consistent care giver on all shifts. Approach resident warmly and positively and in calm manner. Always address resident by name. Calmly talk with resident and offer reassurance prior to initiating care ..." Another Problem listed on the care plan was "I have difficulty in making self understood d/t communication deficits r/t [MEDICAL CONDITION]." The Approaches listed for this problem stated "Ensure consistency in direct t care providers on all shifts." The care plan Problem of "I have periods of behavioral disturbances such as physical and verbal aggression and frequent periods of hollering out r/t [MEDICAL CONDITION] and Dx (diagnosis) of [MEDICAL CONDITION]." The Approaches listed for this problem stated "Approach resident warmly and positively. Provide consistency with direct care providers on all shifts ..." There was also a Problem listed as "I require total assist with all daily ADL's related to [MEDICAL CONDITION] ..." 3. On 4-18-13 at 12:20 p.m. CNA #1 stated that she normally used a towel to rinse residents during a bed bath. She stated that she did not have all the supplies she needed to conduct the 4-17-13 bed bath for Resident #17 at the time she gave it. She further added that she did not know why she did not have the supplies and stated "I don't know. I just didn't have it ..." She added that she had not given a bed bath in a year, but had done this type of patient care work "for [AGE] years." CNA #1 stated that she did not think that resident #17 had a hearing problem and knew that he was blind. When asked why she spoke in a loud tone to resident #17 during the bath, she stated that it was because he could not hear her because he was screaming. When CNA #1 was asked how she was trained to deal with combative residents, she stated she would leave them alone and try to get help. She added that if it had been any other resident (other than resident #17) she would have stopped the procedure, stating "With (Resident #17) it's going to be the same (agitated behavior)." She also added that if she had been scheduled to work all day, she would have left the resident alone, but she had to leave at noon. Review of the personnel records for CNA #1 revealed that the Search Results Texas Nurse Aides form dated 4-11-13 documented that CNA #1 had been a CNA since 3-26-09. CNA #2 was interviewed on 4-18-13 at 1:57 p.m. related to the bed bath CNA #1 gave resident #17 on 4-17-13 at 11:20 a.m. When asked if she would have done anything differently from what she observed CNA #1 do during the bed bath, CNA #2 stated ..."I would have covered (Resident #17) with a light sheet. I wouldn't have poured that water on him like that. I would have changed gloves. I would have covered him properly. I would have changed my towels." She stated "I was going to help her (CNA #1) but she didn't have everything (bed bath supplies). CNA #2 stated prior to the Surveyor entering the room, CNA #1 had used the same towel to clean all the body areas of the resident (perineal and other body areas). She further stated " ...She could have been calmer. She was rushing me too ...She was a little loud." She added that CNA#1 should have called the nurse during the bed bath due to the agitated/combative behavior of the resident. CNA #2 included that CNA #1 had not given her any instructions/information on how to handle resident #17 prior to the bed bath. She added that she had not worked the facility for a while and had "kind of forgot he was blind" since last seeing him. She stated "He hears very well". When asked how she would deal with a combative/agitated resident, CNA #2 stated " ...Me, I would have given him some time and explained what we do. If I came back and he refused, I'd get the charge nurse. We can't force them to do anything. All we can do is ask and try ..." CNA #2 stated she reported the bed bath incident to the DON on 4-17-13. Interview with the ADON on 4-17-13 at 2:07 p.m., revealed related to resident #17 "If talked to calmly, he responds (in a more positive manner). Interview with Family Member #2 revealed that Resident #17 was blind and added "pouring water on someone like this is like drowning ...Pouring water on him would be aggravating ..." She stated "He's totally blind but knows what's going on (mentally) ..." but at times lives in the past. She added that there were no concerns with his hearing. Interview with CNA #3 on 4-17-13 at 12:32 p.m. revealed that Resident #17 was blind and could be physically and verbally abusive, often when he is afraid. She stated " ...If a person is loud and not calm it makes him more agitated." She further stated "a soothing and nice calm voice works best with him." CNA #3 added that when she conducts a bed bath she "changes wash cloths at the peri area" and takes a wash cloth, soaks it in clear water and squeezes enough water on the resident to rinse the soap off the resident. Interview with CNA #5 on 4-18-13 at 10:55 a.m., revealed that that when she rinses a resident off after bathing them, she uses a wet towel. She added "No, I don't pour water over him." She added "He's more agitated when his face is red, he screams hard ..." Interview with CNA #7 on 4-17-13 on 3:20 p.m., revealed that she uses a wash cloth with clear water to rinse off a resident during a bed bath. She added "I use a calm tone with him ...If you keep talking to him (Resident #17), he calms down ...If he thinks you are aggressive he yells more ..." She confirmed that Resident #17 gets more aggressive if a person sounds loud. 4. Regional Vice President Operations stated at 1:47 p.m. on 4-17-13 that the facility had no policy on how bed baths were to be conducted, but would implement the one used for testing for the Nurse Aide (certification) test "from here on." When asked what the facility's expectations were related to conducting a bed bath, he stated at this time, "Rinse with a wet wash cloth is expected. No way it (rinse water) should be poured on ..." When asked how new CNAs were oriented to the facility practices, ADON stated on 4-17-13 at 1:40 p.m. "We put them on the floor with another CNA. No, we have not implemented a skills check list (evaluation) for new CNAs. We will be starting one ..." RN Consultant #1 stated at this time that current CNAs should have a yearly check off to evaluate their skills. He further stated at 1:50 p.m. on 4-17-13 that this evaluation duty would be the responsibility of the DON. Review of the personnel file for CNA #1 revealed a date of hire of 5-18-12. Review of the Texas Nurse Aide Skills Exam sheet dated 7-01-05 documented "Skill #34 COMPLETE BED BATH. Procedural Guideline #21 ...Assemble appropriate equipment before procedure and places it in appropriate place. Provide for resident privacy as appropriate ...Wets washcloth, applies soap (if resident desires) and supervises/assists resident in washing, rinsing (if soap is used) and drying face, ears and neck ...Change bath water at least prior to washing the perineum and as needed during bath to keep the water warm, clean and free of excess soap ...Supervise/assists resident with properly washing, rinsing and drying perineum ... WASHES, RINSES AND DRIES FROM CLEAN TO DIRTY AREAS ..." Review of the facility's current undated CNA Employee Skills Checklist documented " ...INSTRUCTIONS: Indicate by entering the date when the employee demonstrates proficiency with skill ...Bathing ...Bed ..." ~ On 4-18-13, the facility DON submitted a list of residents who required bed baths. Review of the list revealed that it included 2 residents (#9 and #17).

Based on observation, interview and record review, the facility failed to effectively implement written policies and procedures that prohibited mistreatment and neglect, in that: a) CNA #1 was upset while conducting a bed bath for resident #17, who was agitated, combative, blind and dependent ([MEDICAL CONDITION]). During the bed bath (11:20 a.m. to 11:38 a.m. on 4-17-13), CNA #1 used a loud tone of voice and made sarcastic type comments directed at the resident. She slammed a dresser drawer, jerked open a privacy curtain in a quick harsh manner and exhibited rapid/rushed movements. It was a known by other staff (CNAs #3, 5 and 7) and Administration (ADON) who had cared for the resident that Resident #17 responded more positively to a calm environment. Resident #17 ' s care plan stated that a warm, positive and calm manner should be used with the resident. b) During the bed bath, resident #17 yelled the entire time, continuously, "you're hurting me!" , "I'm pissed off!", cursing staff ([***] !) and making gestures with his arms and hands all while his face was red. CNA #1 did not stop the bath or ask for assistance from a nurse, etc. CNA #1 was able to state an accepted way to provide services to an agitated resident, such as stepping away and asking for help, but chose not to with resident #17 because she stated that the resident's resulting behavior would be the same. CNA #1 further stated her number one priority at the time the bath occurred was to leave the facility by noon for personal reasons, c) During the bed bath CNA #1 used the same wash cloth on perineal and other body areas and finally rinsed the resident by pouring a bath basin filled with water all over him from upper chest to feet which soaked the bed/sheets. She later stated that she did not have the proper supplies to rinse the resident. CNA #1 could not state a reason why she did not have the necessary supplies. CNA #1 was able to state an accepted way of rinsing a resident, such as using a wash cloth, and d) Facility did not effectively follow their policy related to Freedom From Abuse or Neglect, Abuse Prevention Program and Recognizing Signs and Symptoms of Abuse/Neglect in that Resident #17 was mistreated by CNA #1. CNA #1 had three past incidents of inappropriate behavior since 1-18-13 that was not effectively addressed. The ineffective implementation of the facility ' s Abuse/neglect prevention program/policy resulted in increased agitation/anguish and discomfort for resident #17, who was blind, dependent ([MEDICAL CONDITION]) and had a history of [REDACTED].#9 and 17). The findings include: 1. On 4-17-13 at 11:19 a.m., the door to Resident #17's room was closed and the resident's voice could be heard coming from the room saying "You're hurting me!" in a loud voice. The surveyor entered the room on 4-17-13 at 11:20 a.m., CNA #1 was observed giving resident #17 a bed bath, along with CNA #2 assisting. Resident #17 yelled repeatedly "I'm pissed off!" and cursed staff ("[***] "), as CNA#1 spoke to the resident in a loud voice and continued wiping the resident with a wet cloth. The resident's face was red as he yelled throughout the procedure. The resident exhibited some physical resistance to care by moving his arms and making gestures with his hands in a limited manner; no lower body resistance/movement was observed. CNA #2 held the resident's hand and talked to the resident in a normal/natural tone of voice during the procedure. Resident #17's genital area was covered with a towel during this time. During the bath CNA #1 gave instructions to the resident in a loud command type tone stating "Breathe!" Count 123 456!", "Turn!", "Rub it (baby powder) in!" etc. At one point in the bath, the resident called staff "[***] ". CNA #1 responded "Really (resident #17). That's how you feel about it?" and "Excuse you!" Towards the end of the bath, CNA #1 rinsed the resident's body by taking a bath basin filled with water and pouring it on the resident from upper chest to feet. This action soaked the bed and sheets. She also slammed the dresser drawer loudly when she retrieved the resident's socks, jerked the privacy curtain backwards/open harshly, had rapid movements and continued to speak in a loud tone of voice. An additional observation of the resident revealed that resident #17 was noted to have a skull deformity and right foot drop. After concluding the bath, CNA #1 left the room and went to the east nurse ' s station and stated in a loud voice " I ' m not changing for nobody, ' cause they are here. " Review of the April 2013 Physician order [REDACTED]. Observation of resident #17 on 4-18-13 at 8:15 a.m. revealed that he was in bed and had scars on his skull and could respond verbally to some questions with difficulty. It was also noted at this time that there was a sign on the wall stating "My name is (Resident #17) I AM BLIND. Please explain what you are doing so I am not scared." In an additional observation of CNA #1 interacting with resident #17, CNA #1 was observed entering resident #17 ' s room at 1:20 p.m. on 4-16-13 and slamming the door. On 4-18-13 at 3:00 p.m., the doors for the resident's room (114) and rooms [ROOM NUMBERS] were checked and it was noted that the doors closed normally without having to be slammed. 2. Review of the most recent MDS Quarterly review dated 2-17-13 documented that the resident had "Adequate" hearing and "Highly Impaired" vision. Bathing Self-Performance was listed as "Total dependence." The MDS also documented Physical behavior symptoms directed toward others as occurring "4 to 6 days", Verbal behavioral symptoms directed toward others as occurring "1 to 3 days" and Other behavior symptoms not directed toward others as occurring "daily." The MDS documented Active [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] documented that the resident had "Adequate" hearing and "Highly Impaired" vision. Bathing Self-Performance was listed as "Total dependence." The MDS also documented Physical behavior symptoms directed toward others as not occurring, Verbal behavioral symptoms directed toward others as occurring "4 to 6 days" and Other behavior symptoms not directed toward others as occurring "daily." It was also documented that these behaviors "significantly interfere with the resident's care." The MDS documented Active [DIAGNOSES REDACTED]. Review of the current care plan dated 7-06-12 stated a problem as "I am legally blind d/t (due to) gunshot to head ..." Another Problem stated was I require assistance in making all daily decisions r/t (related to) [MEDICAL CONDITION]. Under Approaches for this problem it stated " ...Provide consistent direct care givers on all shifts ..." A Problem stated "I have impaired short and long term memory loss r/t [MEDICAL CONDITION]" The Approaches listed for this problem stated "Provide consistent care giver on all shifts. Approach resident warmly and positively and in calm manner. Always address resident by name. Calmly talk with resident and offer reassurance prior to initiating care ..." Another Problem listed on the care plan was "I have difficulty in making self understood d/t communication deficits r/t [MEDICAL CONDITION]." The Approaches listed for this problem stated "Ensure consistency in direct care providers on all shifts." The care plan Problem of "I have periods of behavioral disturbances such as physical and verbal aggression and frequent periods of hollering out r/t [MEDICAL CONDITION] and Dx (diagnosis) of [MEDICAL CONDITION]." The Approaches listed for this problem stated "Approach resident warmly and positively. Provide consistency with direct care providers on all shifts ..." There was also a Problem listed as "I require total assist with all daily ADL's related to [MEDICAL CONDITION] ..." 3. On 4-18-13 at 12:20 p.m. CNA #1 was questioned related to her action during the bed bath she conducted on resident #17 on 4-17-13 at 11:20 a.m. She stated that she normally used a towel to rinse residents during a bed bath. She stated that she did not have all the supplies she needed to conduct the 4-17-13 bed bath for Resident #17 at the time she gave it. She further added that she did not know why she did not have the supplies and stated "I don't know. I just didn't have it ..." She added that she had not given a bed bath in a year, but had done this type of patient care work "for [AGE] years." CNA #1 stated that she did not think that resident #17 had a hearing problem and knew that he was blind. When asked why she spoke in a loud tone to resident #17 during the bath, she stated " ...He can't hear me because he's screaming." When CNA #1 was asked if she explained the rinse procedures to the resident prior to pouring the basin of water on him, she stated that she told him she was going to rinse him but did not tell him she was pouring water on him. CNA #1 was asked why she slammed the dresser drawer and jerked the privacy curtain during the bath. She stated " ...I was getting upset, because I didn't have all my stuff. I hate people watching me ..." When CNA #1 was asked how she was trained to deal with combative residents, she stated she would leave them alone and try to get someone to help. She was then asked why she did not leave resident #17 alone and get assistance during the bed bath. CNA #1 stated " ... If I had been here all day I would have left him alone ...Number one, I was leaving at 12 (noon) and had to pick up my babies. That's first and foremost. If I was here all day I would have left him alone, but it wasn't the other girl's assignment to do him ... With (Resident #17) it's going to be the same (agitated behavior) ..." She added " ...If it had been another resident, I would have left it alone. I know I would ..." Review of the personnel records for CNA #1 revealed that the Search Results Texas Nurse Aides form dated 4-11-13 documented that CNA #1 had been a CNA since 3-26-09. CNA #2 was interviewed on 4-18-13 at 1:57 p.m. related to the bed bath CNA #1 gave resident #17 on 4-17-13 at 11:20 a.m. When asked if she would have done anything differently from what she observed CNA #1 do during the bed bath, CNA #2 stated ..."I would have covered (Resident #17) with a light sheet. I wouldn't have poured that water on him like that. I would have changed gloves. I would have covered him properly. I would have changed my towels." She stated "I was going to help her (CNA #1) but she didn't have everything (bed bath supplies). CNA #2 stated prior to the Surveyor entering the room, CNA #1 had used the same towel to clean all the body areas of the resident (perineal and other body areas). She further stated " ...She could have been calmer. She was rushing me too ...She was a little loud." She added that CNA#1 should have called the nurse during the bed bath due to the agitated/combative behavior of the resident. CNA #2 included that CNA #1 had not given her any instructions/information on how to handle resident #17 prior to the bed bath. She added that she had not worked the facility for a while and had "kind of forgot he was blind" since last seeing him. She stated "He hears very well". When asked how she would deal with a combative/agitated resident, CNA #2 stated " ...Me, I would have given him some time and explained what we do. If I came back and he refused, I'd get the charge nurse. We can't force them to do anything. All we can do is ask and try ..." CNA #2 stated she reported the bed bath incident to the DON on 4-17-13 and added " I can ' t believe she did that (bed bath incident) in front of you. " Interview with the ADON on 4-17-13 at 2:07 p.m., revealed related to resident #17 "If talked to calmly, he responds (in a more positive manner). " Interview with Family Member #2 revealed that Resident #17 was blind and added "pouring water on someone like this is like drowning ... The girl (CNA #1) that did it knows better ...Pouring water on him would be aggravating ..." She stated "He's totally blind but knows what's going on (mentally) ..." but at times lives in the past. She added that there were no concerns with his hearing. The family member also stated "If you talk and be consistent, he's OK ...Tell him what you're doing before touching ..." Interview with CNA #3 on 4-17-13 at 12:32 p.m. revealed that Resident #17 was blind and could be physically and verbally abusive, often when he is afraid. She stated " ...If a person is loud and not calm it makes him more agitated." She further stated " ... a soothing and nice calm voice works best with him." CNA #3 added "If he gets to be too much (agitated) I step out. We try to calm him. His mother counseled us on how to keep him calm, counting to 10 and breathing exercises ..." CNA #3 added "Sometimes when he does his breathing techniques, he [MEDICATION NAME] and sometime I say '[MEDICATION NAME] while you work'. 90% of the time this calms him down ..." CNA #3 added that when she conducts a bed bath she "changes wash cloths at the peri area" and takes another wash cloth, soaks it in clear water and squeezes enough water on the resident to rinse the soap off the resident. Interview with CNA #5 on 4-18-13 at 10:55 a.m., revealed that that when she rinses a resident off after bathing them, she uses a wet towel. She added "No, I don't pour water over him." She added "He's more agitated when his face is red, he screams hard ..." Interview with CNA #7 on 4-17-13 on 3:20 p.m., revealed that she uses a wash cloth with clear water and wipes the resident to rinse off a resident during a bed bath. She added "I use a calm tone with him ...If you keep talking to him (Resident #17), he calms down ...If he thinks you are aggressive he yells more ..." She confirmed that Resident #17 gets more aggressive if a person sounds loud. 4. Review of the facility's POLICY AND PROCEDURE FREEDOM FROM ABUSE OR NEGLECT policy revised 09/13/11 documented "It is the policy of this facility that each resident has the right to be free from mistreatment, neglect ...by anyone, including, but not limited to, facility staff ...Definitions ..."Neglect" is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness ... " The policy further stated " The facility shall: ...3. ...Identify, correct and intervene in situations in which abuse, neglect ....is more likely to occur ...4. Identify events, ...occurrences, patterns and trends that may constitute abuse ... " Review of the facility ' s Abuse Prevention Program revised April 2006 revealed " Policy Statement. Our residents have the right to be free from abuse, neglect ...Policy Interpretation and Implementation. ..3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. Identification of occurrences and patterns of potential mistreatment/abuse; ... " Further review of the facility's abuse and neglect prevention policies revealed the Recognizing Signs and Symptoms of Abuse/Neglect policy revised June 2005 stated " ...3. The following are some examples of actual abuse/neglect and signs and symptoms of abuse/neglect that should be promptly reported. However, this listing is not all-inclusive. Other signs and symptoms or actual abuse/neglect may be apparent. When in doubt, report it ...Signs of/Actual Physical neglect: ...Inadequate provision of care; Caregiver indifference to resident's personal care and needs; ...c. Possible signs/symptoms of psychological abuse/neglect: ...Anger ..." 5. Review of the personnel file for CNA #1 revealed ASSOCIATE CONSTRUCTIVE ADVICE forms. One of the forms dated 1-18-13 documented a written warning that stated an "Incident" of "observed acting in an unprofessional manner during meal service. Used profane and unprofessional language towards a fell ow employee ..." "Goals and Time Frame for Improvement:" documented "Within 30 days Employee will act professional and respectful at all times ..." "The Follow up review date" was "2-06-13." "Consequences" were stated as "progressive discipline up to termination." Another one of the forms dated 2-08-13 documented a written warning that stated an "Incident" of " ...Inefficient/Careless performance of duties ..." "Goals and Time Frame for Improvement:" documented "CNA will complete all assigned tasks accordingly." "The Follow up review date" was "60 days." "Consequences" were stated as "further issues will result in disciplinary action up to and including termination." Another one of the forms dated 4-11-13 documented a final warning that stated an "Incident" of " ...Partaking in behavior that could be considered abuse to a resident ..." "Goals and Time Frame for Improvement:" documented "Mindful of behaviors with residents with impaired decision making skills." There was no "Follow up review date." "Consequences" were stated as "further disciplinary action up to and including termination." 6. During an interview with the Administrator on 4-18-13 at 10:30 a.m. he stated " She (CNA #1) walks around with an attitude. She ' s been talked to ... " The ADON stated at this time that the RN Consultant had spoken to CNA #1 before concerning her behavior. She added that CNA #1 only worked the east corridor (Station 2). ~ On 4-18-13, the facility DON submitted a list of residents who required bed baths. Review of the list revealed that it included 2 residents (#9 and #17).

Based on observation, interview and record review, the facility failed to ensure that CNA #1 provided the services necessary to avoid mistreatment and increased mental anguish in Resident #17 during a bed bath, in that: a) CNA #1 was upset while conducting a bed bath for resident #17, who was agitated, combative, blind and dependent ([MEDICAL CONDITION]). During the bed bath (11:20 a.m. to 11:38 a.m. on 4-17-13), CNA #1 used a loud tone of voice and made sarcastic type comments directed at the resident. She slammed a dresser drawer, jerked open a privacy curtain in a quick harsh manner and exhibited rapid/rushed movements. It was a known by other staff (CNAs #3, 5 and 7) and Administration (ADON) who had cared for the resident that Resident #17 responded more positively to a calm environment. Resident #17 ' s care plan stated that a warm, positive and calm manner should be used with the resident. b) During the bed bath, resident #17 yelled the entire time, continuously, "you're hurting me!" , "I'm pissed off!", cursing staff ([***] !) and making gestures with his arms and hands all while his face was red. CNA #1 did not stop the bath or ask for assistance from a nurse, etc. CNA #1 was able to state an accepted way to provide services to an agitated resident, such as stepping away and asking for help, but chose not to with resident #17 because she stated that the resident's resulting behavior would be the same. CNA #1 further stated her number one priority at the time the bath occurred was to leave the facility by noon for personal reasons, and c) During the bed bath CNA #1 used the same wash cloth on perineal and other body areas and finally rinsed the resident by pouring a bath basin filled with water all over him from upper chest to feet which soaked the bed/sheets. She later stated that she did not have the proper supplies to rinse the resident. CNA #1 could not state a reason why she did not have the necessary supplies. CNA #1 was able to state an accepted way of rinsing a resident, such as using a wash cloth. These problems resulted in increased agitation/anguish and discomfort for resident #17, who was blind, dependent ([MEDICAL CONDITION]) and had a history of [REDACTED].#9 and 17). The findings include: 1. On 4-17-13 at 11:19 a.m., the door to Resident #17's room was closed and the resident's voice could be heard coming from the room saying "You're hurting me!" in a loud voice. The surveyor entered the room on 4-17-13 at 11:20 a.m., CNA #1 was observed giving resident #17 a bed bath, along with CNA #2 assisting. Resident #17 yelled repeatedly "I'm pissed off!" and cursed staff ("[***] "), as CNA#1 spoke to the resident in a loud voice and continued wiping the resident with a wet cloth. The resident's face was red as he yelled throughout the procedure. The resident exhibited some physical resistance to care by moving his arms and making gestures with his hands in a limited manner; no lower body resistance/movement was observed. CNA #2 held the resident's hand and talked to the resident in a normal/natural tone of voice during the procedure. Resident #17's genital area was covered with a towel during this time. During the bath CNA #1 gave instructions to the resident in a loud command type tone stating "Breathe!" Count 123 456!", "Turn!", "Rub it (baby powder) in!" etc. At one point in the bath, the resident called staff "[***] ". CNA #1 responded "Really (resident #17). That's how you feel about it?" and "Excuse you!" Towards the end of the bath, CNA #1 rinsed the resident's body by taking a bath basin filled with water and pouring it on the resident from upper chest to feet. This action soaked the bed and sheets. She also slammed the dresser drawer loudly when she retrieved the resident's socks, jerked the privacy curtain backwards/open harshly, had rapid movements and continued to speak in a loud tone of voice. An additional observation of the resident revealed that resident #17 was noted to have a skull deformity and right foot drop. After concluding the bath, CNA #1 left the room and went to the east nurse ' s station and stated in a loud voice " I ' m not changing for nobody, ' cause they are here. " Review of the April 2013 Physician order [REDACTED]. Observation of resident #17 on 4-18-13 at 8:15 a.m. revealed that he was in bed and had scars on his skull and could respond verbally to some questions with difficulty. It was also noted at this time that there was a sign on the wall stating "My name is (Resident #17) I AM BLIND. Please explain what you are doing so I am not scared." In an additional observation of CNA #1 interacting with resident #17, CNA #1 was observed entering resident #17 ' s room at 1:20 p.m. on 4-16-13 and slamming the door. On 4-18-13 at 3:00 p.m., the doors for the resident's room (114) and rooms [ROOM NUMBERS] were checked and it was noted that the doors closed normally without having to be slammed. 2. Review of the most recent MDS Quarterly review dated 2-17-13 documented that the resident had "Adequate" hearing and "Highly Impaired" vision. Bathing Self-Performance was listed as "Total dependence." The MDS also documented Physical behavior symptoms directed toward others as occurring "4 to 6 days", Verbal behavioral symptoms directed toward others as occurring "1 to 3 days" and Other behavior symptoms not directed toward others as occurring "daily." The MDS documented Active [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] documented that the resident had "Adequate" hearing and "Highly Impaired" vision. Bathing Self-Performance was listed as "Total dependence." The MDS also documented Physical behavior symptoms directed toward others as not occurring, Verbal behavioral symptoms directed toward others as occurring "4 to 6 days" and Other behavior symptoms not directed toward others as occurring "daily." It was also documented that these behaviors "significantly interfere with the resident's care." The MDS documented Active [DIAGNOSES REDACTED]. Review of the current care plan dated 7-06-12 stated a problem as "I am legally blind d/t (due to) gunshot to head ..." Another Problem stated was I require assistance in making all daily decisions r/t (related to) [MEDICAL CONDITION]. Under Approaches for this problem it stated " ...Provide consistent direct care givers on all shifts ..." A Problem stated "I have impaired short and long term memory loss r/t [MEDICAL CONDITION]" The Approaches listed for this problem stated "Provide consistent care giver on all shifts. Approach resident warmly and positively and in calm manner. Always address resident by name. Calmly talk with resident and offer reassurance prior to initiating care ..." Another Problem listed on the care plan was "I have difficulty in making self understood d/t communication deficits r/t [MEDICAL CONDITION]." The Approaches listed for this problem stated "Ensure consistency in direct care providers on all shifts." The care plan Problem of "I have periods of behavioral disturbances such as physical and verbal aggression and frequent periods of hollering out r/t [MEDICAL CONDITION] and Dx (diagnosis) of [MEDICAL CONDITION]." The Approaches listed for this problem stated "Approach resident warmly and positively. Provide consistency with direct care providers on all shifts ..." There was also a Problem listed as "I require total assist with all daily ADL's related to [MEDICAL CONDITION] ..." 3. On 4-18-13 at 12:20 p.m. CNA #1 was questioned related to her action during the bed bath she conducted on resident #17 on 4-17-13 at 11:20 a.m. She stated that she normally used a towel to rinse residents during a bed bath. She stated that she did not have all the supplies she needed to conduct the 4-17-13 bed bath for Resident #17 at the time she gave it. She further added that she did not know why she did not have the supplies and stated "I don't know. I just didn't have it ..." She added that she had not given a bed bath in a year, but had done this type of patient care work "for [AGE] years." CNA #1 stated that she did not think that resident #17 had a hearing problem and knew that he was blind. When asked why she spoke in a loud tone to resident #17 during the bath, she stated " ...He can't hear me because he's screaming." When CNA #1 was asked if she explained the rinse procedures to the resident prior to pouring the basin of water on him, she stated that she told him she was going to rinse him but did not tell him she was pouring water on him. CNA #1 was asked why she slammed the dresser drawer and jerked the privacy curtain during the bath. She stated " ...I was getting upset, because I didn't have all my stuff. I hate people watching me ..." When CNA #1 was asked how she was trained to deal with combative residents, she stated she would leave them alone and try to get someone to help. She was then asked why she did not leave resident #17 alone and get assistance during the bed bath. CNA #1 stated " ... If I had been here all day I would have left him alone ...Number one, I was leaving at 12 (noon) and had to pick up my babies. That's first and foremost. If I was here all day I would have left him alone, but it wasn't the other girl's assignment to do him ... With (Resident #17) it's going to be the same (agitated behavior) ..." She added " ...If it had been another resident, I would have left it alone. I know I would ..." Review of the personnel records for CNA #1 revealed that the Search Results Texas Nurse Aides form dated 4-11-13 documented that CNA #1 had been a CNA since 3-26-09. CNA #2 was interviewed on 4-18-13 at 1:57 p.m. related to the bed bath CNA #1 gave resident #17 on 4-17-13 at 11:20 a.m. When asked if she would have done anything differently from what she observed CNA #1 do during the bed bath, CNA #2 stated ..."I would have covered (Resident #17) with a light sheet. I wouldn't have poured that water on him like that. I would have changed gloves. I would have covered him properly. I would have changed my towels." She stated "I was going to help her (CNA #1) but she didn't have everything (bed bath supplies). CNA #2 stated prior to the Surveyor entering the room, CNA #1 had used the same towel to clean all the body areas of the resident (perineal and other body areas). She further stated " ...She could have been calmer. She was rushing me too ...She was a little loud." She added that CNA#1 should have called the nurse during the bed bath due to the agitated/combative behavior of the resident. CNA #2 included that CNA #1 had not given her any instructions/information on how to handle resident #17 prior to the bed bath. She added that she had not worked the facility for a while and had "kind of forgot he was blind" since last seeing him. She stated "He hears very well". When asked how she would deal with a combative/agitated resident, CNA #2 stated " ...Me, I would have given him some time and explained what we do. If I came back and he refused, I'd get the charge nurse. We can't force them to do anything. All we can do is ask and try ..." CNA #2 stated she reported the bed bath incident to the DON on 4-17-13 and added " I can ' t believe she did that (bed bath incident) in front of you. " Interview with the ADON on 4-17-13 at 2:07 p.m., revealed related to resident #17 "If talked to calmly, he responds (in a more positive manner). " Interview with Family Member #2 revealed that Resident #17 was blind and added "pouring water on someone like this is like drowning ... The girl (CNA #1) that did it knows better ...Pouring water on him would be aggravating ..." She stated "He's totally blind but knows what's going on (mentally) ..." but at times lives in the past. She added that there were no concerns with his hearing. The family member also stated "If you talk and be consistent, he's OK ...Tell him what you're doing before touching ..." Interview with CNA #3 on 4-17-13 at 12:32 p.m. revealed that Resident #17 was blind and could be physically and verbally abusive, often when he is afraid. She stated " ...If a person is loud and not calm it makes him more agitated." She further stated " ... a soothing and nice calm voice works best with him." CNA #3 added "If he gets to be too much (agitated) I step out. We try to calm him. His mother counseled us on how to keep him calm, counting to 10 and breathing exercises ..." CNA #3 added "Sometimes when he does his breathing techniques, he [MEDICATION NAME] and sometime I say '[MEDICATION NAME] while you work'. 90% of the time this calms him down ..." CNA #3 added that when she conducts a bed bath she "changes wash cloths at the peri area" and takes another wash cloth, soaks it in clear water and squeezes enough water on the resident to rinse the soap off the resident. Interview with CNA #5 on 4-18-13 at 10:55 a.m., revealed that that when she rinses a resident off after bathing them, she uses a wet towel. She added "No, I don't pour water over him." She added "He's more agitated when his face is red, he screams hard ..." Interview with CNA #7 on 4-17-13 on 3:20 p.m., revealed that she uses a wash cloth with clear water and wipes the resident to rinse off a resident during a bed bath. She added "I use a calm tone with him ...If you keep talking to him (Resident #17), he calms down ...If he thinks you are aggressive he yells more ..." She confirmed that Resident #17 gets more aggressive if a person sounds loud. 4. Review of the facility's POLICY AND PROCEDURE FREEDOM FROM ABUSE OR NEGLECT policy revised 09/13/11 documented "It is the policy of this facility that each resident has the right to be free from mistreatment, neglect ...by anyone, including, but not limited to, facility staff ...Definitions ..."Neglect" is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness ..." Further review of the facility's abuse and neglect prevention policies revealed the Recognizing Signs and Symptoms of Abuse/Neglect policy revised June 2005 stated " ...3. The following are some examples of actual abuse/neglect and signs and symptoms of abuse/neglect that should be promptly reported. However, this listing is not all-inclusive. Other signs and symptoms or actual abuse/neglect may be apparent. When in doubt, report it ...Signs of/Actual Physical neglect: ...Inadequate provision of care; Caregiver indifference to resident's personal care and needs; ...c. Possible signs/symptoms of psychological abuse/neglect: ...Anger ..." 5. Review of the personnel file for CNA #1 revealed ASSOCIATE CONSTRUCTIVE ADVICE forms. One of the forms dated 1-18-13 documented a written warning that stated an "Incident" of "observed acting in an unprofessional manner during meal service. Used profane and unprofessional language towards a fell ow employee ..." "Goals and Time Frame for Improvement:" documented "Within 30 days Employee will act professional and respectful at all times ..." "The Follow up review date" was "2-06-13." "Consequences" were stated as "progressive discipline up to termination." Another one of the forms dated 2-08-13 documented a written warning that stated an "Incident" of " ...Inefficient/Careless performance of duties ..." "Goals and Time Frame for Improvement:" documented "CNA will complete all assigned tasks accordingly." "The Follow up review date" was "60 days." "Consequences" were stated as "further issues will result in disciplinary action up to and including termination." Another one of the forms dated 4-11-13 documented a final warning that stated an "Incident" of " ...Partaking in behavior that could be considered abuse to a resident ..." "Goals and Time Frame for Improvement:" documented "Mindful of behaviors with residents with impaired decision making skills." There was no "Follow up review date." "Consequences" were stated as "further disciplinary action up to and including termination." Further review of the Individual Completed Education record for CNA #1 revealed that she had been inserviced/trained related to " Preventing, Recognizing and Reporting Resident Abuse " on 6-07-12. 6. During an interview with the Administrator on 4-18-13 at 10:30 a.m. he stated " She (CNA #1) walks around with an attitude. She ' s been talked to ... " The ADON stated at this time that the RN Consultant had spoken to CNA #1 before concerning her behavior. She added that CNA #1 only worked the east corridor (Station 2). ~ On 4-18-13, the facility DON submitted a list of residents who required bed baths. Review of the list revealed that it included 2 residents (#9 and #17).