Every finding on record at Harmony Care at Beaumont

Based on interview, and record review, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for 1 of 3 residents (Resident #1) reviewed for discharges.The facility discharged Resident #1 on 07/21/26 to a private care home that was not aware of the level of care Resident #1 required and the facility did not ensure the private care home could meet his medical needs.The facility failed to follow their discharge planning policy and federal regulations when they did not implement an effective discharge planning process for Resident #1 to ensure his discharge rights were not violated.Resident #1 was located by his legal guardian on 08/13/26 at an unlicensed facility and observed in a urine-soaked brief with his rib cage and sternum (long flat bone in the middle of the chest) visible. Resident #1 was unable to stand on his own, and had developed multiple additional wounds to his back, buttocks, scrotum (external pouch of skin that holds and protects the testicles), and heels. There were no staff present in the home. Resident #1 was transferred to the hospital and received treatment for hypernatremia (blood has too much sodium), malnutrition (too few, too many, or wrong mix of nutrients), dehydration (body loses more fluid than it takes in), and electrolyte imbalances (key minerals become too high or too low that could disrupt nerve signals and muscle and heart function). Resident #1 remained in ICU as of 08/19/26 with an undetermined prognosis.An IJ was identified on 08/18/26. The IJ template was provided to the facility on [DATE] at 1:02 p.m. While the IJ was removed on 08/19/26, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.The failures could place residents at risk for serious injury, harm, and/or death if they are not provided a safe and appropriate discharge to meet their health needs. Findings included: Record review of Resident #1's face sheet dated 08/14/26 indicated he was a [AGE] year old male, admitted to the facility on [DATE], and his diagnoses included diffuse traumatic brain injury (happens when rapid rotation or shaking of the head causes the brain's connecting nerve fibers to stretch or tear), hypertension (high blood pressure), degenerative disease of the nervous system (nerve cells in the brain or spinal cord progressively lose structure, function, and eventually die), severe dementia with agitation (intense emotional distress, pacing, yelling, or physical aggression), seizures (sudden burst of abnormal electrical activity in the brain), encephalopathy (a general term for any disease, damage, or overall dysfunction of the brain), cognitive communication deficit (breakdown in communication caused by impaired thinking process), major depressive disorder (mental health condition), and generalized anxiety disorder (mental health condition). Record review of Resident #1's Letter of Guardianship (uploaded to Resident #1's electronic record on 06/15/26 by the DON) indicated an effective date of 10/15/25 (expiration date 02/09/27). Record review of Resident #1's ADL Only Evaluation dated 02/05/26 indicated he was independent or required 1 person assist for bed mobility. He required supervision or required 1 person assist to transfer. He required supervision or set up for eating. He required one person assist to total dependence for toileting and personal hygiene. He required supervision or one person assist to walk in his room. He required one-person physical assist to total dependence for dressing. Record review of Resident #1's physician's orders dated 02/21/25 indicated Plan for Discharge, there was no discharge order. Review of Resident #1's quarterly MDS assessment dated [DATE] indicated he had no speech, was sometimes able to make himself understood and sometimes understood others. He had severe cognitive impairment. He was always incontinent of bladder and bowel. The MDS reflected for Discharge planning - no active planning already occurring for resident to return to the community. Record review of Resident #1's care plan dated 02/10/26 indicated Resident #1/RP have chosen to remain in the facility for LTC and did not wish to be asked about returning to the community on all assessments. Record review of Resident #1's care plan dated 04/15/26 indicated he had an ADL self-care performance deficit related to dementia, impaired balance, and limited mobility. Interventions included total dependence on 1 staff for bath/shower, bed mobility, dressing, eating, personal hygiene, oral care, toilet use, and transfers. Record review of Resident #1's Care Conference Review notes dated 06/03/26 at 10:20 a.m. (unsigned) indicated Resident #1 was invited and attended the care conference. There was no family/RP or guardian invited or attended. The Discharge Planning section indicated there was no plan for discharge. Resident #1 remained on the LOA program. Resident #1 had a party listed on the face sheet, but there was no answer when contact was attempted (party was unidentified). There was no documentation the guardian was notified. Record review of Resident #1's social service note dated 06/05/26 at 11:21 a.m., completed by SW F indicated Guardian G was at the facility and replaced previous Guardian M. Guardian G said Resident #1 had two children but was not able to provide any information. Guardian G reviewed Resident #1's care plan and provided her contact number. Record review of Resident #1's nurse note dated 06/16/26 at 11:38 a.m., completed by the DON indicated the DON spoke with Resident #1's family member and advised her the LOA contract would end in 30 days. Informed family member of need to schedule care plan meeting with clinical team and Case Manger D. There was no communication noted with Resident #1's guardian. Record review of Resident #1's communication note dated 06/18/26 at 3:12 p.m., completed by the DON indicated Resident #1's family member and Case Manager D to discuss discharge plans for Resident #1. Family was informed Resident #1 had a discharge date anticipated for 30 days. There was no communication noted with Resident #1's guardian. Record review of Resident #1's medical professional note dated 07/15/26 at 11:38 a.m., completed by NP A indicated Resident #1 had cognitive and memory impairment and cognitive functional decline. It was medically necessary to have care in a nursing home/long term care facility setting in order to assist with ADLS and IADLS (are more advanced tasks that require complex thinking, organization, and interaction with the community). It was necessary to have frequent re-direction and re-orientation by staff. Record review of Resident #1's plan of care note dated 07/15/26 at 3:13 p.m., completed by the DON, indicated she contacted Resident #1's family member. Resident #1's family member was not able to pick up Resident #1 as she had no one to care for him and no place for him to stay. SW F was aware and would follow all necessary procedures and protocols. There was no communication noted with Resident #1's guardian. Record review of Resident #1's social service note dated 07/15/26 at 3:23 p.m., completed by SW F indicated she called APS because Resident #1's family member refused to pick up Resident #1 on 07/15/26. SW F did not call the guardian. Record review of Resident #1's social service note dated 07/15/26 at 4:10 p.m., completed by SW F, indicated she attempted to contact the ombudsman and was unable to reach her and left a message at (incorrect extension noted). Record review of Resident #1's weekly wound observation tool dated 07/15/26 indicated he had a new acquired incontinence associated dermatitis on his scrotum. There was no drainage or odor. It was 1 cm x 2 cm and had a depth of 0.1 cm. There was no discharge assessment available for review. Record review of text messages, provided by the DON on 08/14/26 at 1:15 p.m., between the facility's previous corporate BOM T and SW P dated 07/15/26 at 2:26 p.m. indicated SW P texted APS and guardianship needs to be informed . Record review of continued text messages, provided by the DON on 08/14/26 at 1:15 p.m., between the facility's previous corporate BOM T dated 07/16/26 at 11:16 p.m. indicated SW P texted Social worker (SW F) is calling APS. Guardianship is aware as well. Record review of plan of care note dated 07/17/26 at 1:30 p.m., completed by the DON, indicated the DON spoke with Resident #1's family member and Case Manager D at (named hospital) to discuss planned discharge for Resident #1. Resident #1's family member was informed the (named hospital) would fund 90 days of care with a PCH. After 90 days, the family member and family would be responsible for Resident #1's care. Resident #1's family member agreed. Family Member N to contact Owner E to confirm placement of Resident #1. The DON did not call the guardian. Record review of Resident #1's plan of care note dated 07/20/26 at 10:00 a.m., completed by the DON, indicated Resident #1 was confirmed to be transported to (named UALF/private care home). Report given to Owner E. Transportation arranged via stretcher with ambulance to unnamed address in [local city and state]. The DON did not call the guardian. Record review of Resident #1's nurse note dated 07/20/26 at 8:20 p.m., completed by TX LVN B, indicated Resident #1 would be transported to (unnamed address) in [local city and state]. TX LVN B did not call the guardian. Record review of Resident #1's nurse note dated 07/21/26 at 8:51 p.m., completed by TX LVN B, indicated Resident #1 left the facility via ambulance transport to a new home. He was clean and appropriately prepared for discharge. Resident #1 had no problems or concerns noted at the time of departure and left facility in stable condition. During an interview on 08/13/26 at 5:02 p.m., Resident #1's Guardian G said she visited Resident #1 on 06/04/26 at the facility. He was sitting in bed and was being fed by a staff. Staff reported he would eat well but was unable to be up and out of bed for a long period of time. Staff reported Resident #1's family members visited and spoke with him. He was clean and dressed and there were no odors. He remained in bed and required assistance due to weakness. She said the facility was provided with the letters of guardianship and her contact information. She said she sent the letter of guardianship to SW F on 06/12/26 via email. She said on 06/18/26, SW F indicated Resident #1 was on the LOA program from (named hospital). She said she visited with Resident #1 on 07/07/26 and he was being assisted by facility staff with care and being dressed in a hospital gown. She said staff reported Resident #1 was being dressed in hospital gowns because it was easier to clean him and assist with his care needs. Staff reported he rarely got out of bed, and he was a fall risk due to his fragile condition. She said she received a call from SW F on 07/15/26 regarding Resident #1s discharge status, and he was being discharged that day after being notified by the LOA program that a request for an extension was denied. She said SW F indicated she (SW F) had not received a formal discharge notice from the facility and was not sure where he would be discharged . She said she advised SW F Resident #1 could not be discharged without appropriate placement. Guardian G said as of 07/15/26 she had not received formal discharge notice of Resident #1's discharge or a request for authorization of Resident #1's discharge. She said she notified the guardian agency of the facility's planned discharge of Resident #1 and was informed the facility could not discharge the resident without an appropriate place to go. Guardian G said she went to the facility on [DATE]. She said SW F indicated she did not know if Resident #1 had been moved or was still in the facility. Guardian G said she discovered Resident #1 was no longer in the facility, his bed had been cleared and his clothing had been given to another resident. She said Resident #1's family member had signed the discharge paperwork and provided the authorization to the facility for his discharge. She said she advised SW F Resident #1's family member was not his legal guardian and was not authorized to provide consent for his discharge. She said SW F said Resident #1 was moved to a home provider the LOA program had agreed to pay for an additional 90 days. She said SW F did not provide the actual date Resident #1 was discharged or where he was moved. She said at the time of the visit to the facility on [DATE], she (Guardian G) had not received a formal discharge notice, discharge plan, request for authorization, confirmed discharge date , or complete information regarding Resident #1's new placement. She said on 07/27/26 she emailed SW F and requested Resident #1's new placement address. She said she received Resident #1's address from SW F on 07/28/26 but SW F did not know if it was lane or street. She said she was in another city (further away) and she had received an email from her supervisor to go to the address but she was not in the area. Her supervisor thought that one of the other agents would go to the address but they thought she was going so there was some kind of miscommunication. She said she went to the address on 08/13/26 and found Resident #1 in a urine-soaked brief with his rib cage and sternum visible. He was unable to stand on his own, and had developed multiple additional wounds to his back, buttocks, scrotum, and heels. There were no staff present in the home, and other individuals residing at the home indicated staff were often away from the home. Guardian G said Resident #1 was transferred to the hospital and admitted to ICU on 08/13/26. She said Resident #1 received treatment for hypernatremia, malnutrition, dehydration, and electrolyte imbalances. She said the facility discharged Resident #1 to a facility that could not meet his needs. She said Resident #1 had stopped talking, walking, and his right arm was so stiff the hospital staff had to move it out of the way to complete a chest x-ray. She said the LOA (named hospital) indicted they were not aware Resident #1 required more care, that he was able except for requiring supervision due to dementia, and were not aware he had a guardian. She said the facility and LOA (named hospital) were both responsible for placing Resident #1 in an unsafe environment. She said she would not have approved his discharge to the place where he was located. She said guardianship would never approve of transfer to a lower level of care. She said neither the facility nor the Administrator communicated to her regarding Resident #1's discharge from the facility. Record review of 5 pictures (undated) of Resident #1's condition when he was found in the UALF/group home on [DATE], provided by Guardian G on 08/16/26, indicated:Picture #1-bed with no sheet, a plastic sheet and blanket and pillow covered in unknown brownish/red substance.Picture #2-Resident #1 dressed only in a brief, in a fetal position on the same bed noted in Picture #1 with his arms drawn across his chest. His ribs, hip bones, knee bones were visible; he was gaunt and malnourished appearing with a sunken stomach.Picture #3-Resident #1 covered with the blanket that was covered with brownish/red substance/stains noted in Picture #1.Picture #4-Resident #1's ribs visible.Picture #5-Resident #1 was on his left side. Resident #1's back had peeling skin, and there were pieces of his skin and an unknown brownish/red substance on the plastic sheet. Record review of the EMS transport dated 07/21/26 indicated Resident #1 was found in semi-Fowler's position (posture where the head and upper body are elevated 30 to 45 degrees to promote comfort, breathing, and physiological support) and unable to walk due to a TBI. He was moved from a wheelchair to a stretcher and secured with 3 straps and 2 side rails. He arrived at the group home and was taken to a room and moved to a bed using a draw sheet. He was secured in bed with bed rails in an up position and locked. A full report and all patient care documents were given to caregiver (unnamed). Record review of Resident #1's hospital record dated 08/13/26 indicated he was admitted to the ICU with severe hypernatremia (blood has too much sodium) and malnutrition. He had pressure ulcers on his hip, sacrum, and malleoli (hard, bone bumps on either side of the ankle). Resident #1 was visibly malnourished. Resident #1 was discharged from the NF without communication. Resident #1 was found in a group home with signs of neglect and malnourishment. Resident #1 was in acute distress. He had severe bony prominences to his shoulders and knees due to malnutrition. His ribs were visible. There was a scaphoid (sunken) abdomen. Resident #1 was critically ill due to presenting with an illness that impaired one or more vital organ systems. There was a probability of imminent or life-threatening deterioration in Resident #1's condition. During an interview on 08/14/26 at 10:10 a.m., the Administrator said there were no residents given a 30-day notice of discharge within the previous 30 days. She said there were no forced discharges, and no residents were discharged against their will. She said it was her expectations that all discharges were completed per policy. During an interview on 08/14/26 at 1:07 p.m., the DON said Resident #1 was an LOA resident under contact with (named hospital). She said (named hospital) paid for Resident #1's stay. She said they decided to end the contract and requested the facility discharge Resident #1. She said the (named hospital) gave orders for Resident #1's discharge because they would no longer pay for services. She said Resident #1 was not a citizen or legal resident and could not receive Medicaid and did not have long-term care insurance. She said she did not know who signed for the discharge. The DON said SW F called APS when Resident #1's family member refused to pick him up from the facility. The DON said she was not aware of Resident #1 having a guardian. She said she did upload the guardianship papers into Resident #1's electronic record but forgot. She said Guardian G took over Resident #1's case as of 06/05/26. She said she was not aware a care plan was not completed for Resident #1's guardianship status. She said SW F should have contacted Guardian G about the planned discharge. She said Resident #1 was totally dependent for his care. She said when Resident #1 was transferred to the new facility on 07/21/26, the transport company was given Resident #1's face sheet, medication list, and progress notes to give to the new facility. During an interview on 08/14/26 at 1:30 p.m., CNA I said Resident #1 rarely got out of bed, was totally dependent for all care, including being fed. During an interview on 08/14/26 at 1:38 p.m., CNA J said Resident #1 was totally dependent for all care including dressing, shaving, oral hygiene, baths, nails, hair, and feeding. During an interview on 08/14/26 at 1:43 p.m., TX LVN B said Resident #1 was totally dependent for all care. She said sometimes he would need assistance with feeding. She said he would sometimes nod his head yes or shake his head no but was non-verbal for communication. She said she had never heard him speak. During an interview on 08/14/26 at 2:25 p.m., the ADON said she was not aware Resident #1 had a guardian until after Resident #1 was discharged from the facility. She said she was not aware previously aware of who Guardian G was until one of her visits to the facility. She said Guardian G asked about other residents but did not ask about Resident #1's pending discharge. She said Resident #1's family member showed up to visit one weekend in June 2026 and once the LOA (named hospital) found out, they were ready to cut all ties with Resident #1. During an interview on 08/14/26 at 3:13 p.m., the DON said the facility had weekly meetings with the LOA (named hospital). She said they were only asked about Resident #1's weight. She said the LOA (named hospital) did not request any documents and the facility did not send any documents regarding Resident #1's medical or health status. During an interview on 08/14/26 at 3:35 p.m., the Administrator said Resident #1 was on a LOA contract with (named hospital). She said (named hospital) contacted the facility to transfer Resident #1 to another facility. She said (named hospital) would decide if they were going to continue payment for Resident #1's stay at the facility. She said SW F was to make sure Resident #1 was safely discharged under the previous owner of the facility. She said the previous owner of the company handled the LOA contract with (named hospital). During an interview on 08/17/26 at 8:20 a.m., NP A said Resident #1 was dependent for all ADLS. She said she was not made aware of Resident #1's planned discharge. She said MD K was involved with facility discharges. She said she was not aware Resident #1 had a guardian. During an interview on 08/17/26 at 8:54 a.m., the Ombudsman said she was not informed of Resident #1's planned discharge or discharge from the facility. She said she had not received a written discharge notice from the facility. During an interview on 08/17/26 at 9:07 a.m., Owner E said she received Resident #1 from a nursing facility. She said she agreed to take Resident #1 to her facility but on the date he was discharged (07/21/26) from the facility, she did not have an open bed so she arranged for Resident #1 to go to another location. She said she informed Resident #1's family member who toured the new location and said the resident was fine to go there. She said she was informed from (named hospital) that Resident #1 was able to do things for himself and could walk but chose not to walk. She said she was not aware he was dependent for care. She said she was not aware Resident #1 had a guardian. She said she was told Resident #1 required temporary placement until his family member found a place to live. She said she never had communication with anyone from the nursing facility. She said she communicated with the(unnamed hospital) During an interview on 08/17/26 at 10:18 a.m., MD K said he was not aware Resident #1 was discharged to an unlicensed facility. He said he did not think the facility should be held at fault for the condition Resident #1 was found in. He said Resident #1 required assistance for all ADLS. He said he was not aware there was no care plan for discharge, no orders for discharge, or no discharge summary. He said when he found out about Resident #1's discharge (after investigator entrance), he and the DON had discussed discharge summaries and what should be recorded, going forward. He said he was not happy he could not find the summary in Resident #1's record. He said he agreed it would be a failure of the facility if they did not complete a discharge as required by the regulations. He said residents were at risk of not receiving proper care if they were discharged to a lower level of care than what they required. During an interview on 08/17/26 at 11:27 a.m., RN L said she was aware of the LOA for Resident #1. She said she was not aware there were no physician's orders for discharge, no discharge care plan, and no discharge summary for Resident #1. He and the physician's orders and transfer documentation were supposed to be sent to the receiving facility for continuity of care. She said all 30-day discharges were discussed at weekly meetings. She said the guardian and ombudsman should have been notified of the planned discharge. She said she was not aware Resident #1 was discharged to an unlicensed facility with a lower level of care. During an interview on 08/17/26 at 2:38 p.m., the DON said the (named hospital) found the facility for Resident #1 to be discharged to. She said she did not know Resident #1 was not transferred to the intended care home. She said she advised (named hospital) that Resident #1 was dependent/total care. During an interview on 08/17/26 at 7:36 p.m., Family member A said Resident #1 was removed from the contract home on [DATE] by his guardian. She said she was not aware Resident #1 had a guardian. She said she did not remember who informed her of Resident #1's location. She said (named hospital) agreed to pay for Resident #1's stay in the contract home. She said he was transferred to the contract home from the nursing facility. She said the facility said they were going to discharge Resident #1 because the LOA contract had ended at the facility, but (named hospital) extended it for 90 days at the contract home. She said she explained to the facility she could not take Resident #1 home because there was no space for him, and she had no one to care for him. She said Owner E and Owner O informed her of Resident #1 being transported to hospital on [DATE]. During an interview on 08/17/26 at 2:50 p.m., SW F said the (named hospital) found Resident #1's placement. She said she forgot to contact the Ombudsman about Resident #1's planned discharge or discharge. She said she did not send written notice. She said she only wrote a note in Resident #1's electronic record. She said she was not aware of the facility's discharge policy or the federal regulations related to resident discharges. She said she had become aware of the facility policy and federal regulations for resident discharges after Resident #1 was discharged . She said Resident #1 was totally dependent for care. She said the address she provided the guardian was where he was found by the guardian. She said she attempted to call the guardian prior to Resident #1's discharge but did not make contact. She said she did not send the guardian written notice of the planned discharge or notify the guardian of Resident #1's actual discharge. She said (named hospital) found placement for Resident #1 to be discharged to. During an interview on 08/17/26 at 4:00 p.m., AVP Q (of the unnamed hospital) said the facility and the hospital team met weekly with the facility regarding Resident #1. AVP Q said in the meeting the facility indicated Resident #1 was able walk, talk, and care for himself. AVP Q said the family had re-engaged and that could end the LOA contract. AVP Q said the 30-day notice to end the payment contract was sent to Resident #1's family member. AVP Q said she was not aware nor did the facility inform them that Resident #1 had a guardian. AVP Q said if they had known Resident #1 had a guardian he would have been discharged immediately from the payor source program. AVP Q said (named hospital) was the payor to the facility and was not in charge of Resident #1's discharge planning process from the nursing facility. AVP Q said (named hospital) agreed to pay for 90 days at (named personal care home) but was unaware Resident #1 was discharged to a different unlicensed care home. AVP Q said she was not aware Resident #1 was discharged to an unlicensed facility although the unlicensed home was recommended by AVP Q's organization. AVP Q said the unlicensed home was credentialed prior to her recommendations and they would never recommend an individual to be cared for in an unlicensed facility. AVP Q said the (named hospital) received Resident #1's information verbally at weekly meetings and never received any written clinical information. During an interview on 08/17/26 at 4:00 p.m., SW P said she had communicated with RN L and Resident #1's Family Member N to confirm agreement with the plans to discharge Resident #1 with an agreement to continue paying for Resident #1's stay at the new facility for 90 days. SW P said she was not aware Resident #1 had an appointed guardian. SW P said she requested Resident #1's clinical information be sent to Owner E at the new facility. SW P said she had communicated with Owner E and she had confirmed she accepted Resident #1. During an interview on 08/18/26 at 8:19 a.m., Owner O (of UALF) said Resident #1's family member toured the facility and provided the information for Resident #1. She said she did not receive clinical information from EMS transport. She said Family Member N said Resident #1 was able to care for himself and walk but he sometimes chose not to. She said her facility was not licensed. She said she was a permitted group home through the city. She said she received Resident #1's hospital records dated 07/25/25 (from named hospital) from Owner E. Owner O said Resident #1 was walking and talking. She said she was not aware Resident #1 had a guardian. She said Resident #1 declined after he was transferred to her facility on 07/21/26. She said she was trying to assist Family Member N to obtain alternate placement and resources. She said she would not have accepted Resident #1 had she known he required 100% care. She said she was not aware the staff had left the group home, and residents were not attended to on 08/13/26. She said Resident #1's wounds were leaking, and his sheets were in the wash when he was found on 08/13/26. She said he did not receive nursing care from 07/21/26 though 08/13/26. During an interview on 08/18/26 at 10:20 a.m., TX LVN B said Resident #1 was clean and dressed in his clothes for discharge on [DATE]. She said he was transported via stretcher to the new provider. She said the wound on his scrotum had resolved as of his discharge on [DATE]. She said he was not able to walk or talk, required feeding assist and incontinent care. She said her involvement with his discharge included setting up his transportation after receiving the order from the DON. During an interview on 08/18/26 at 2:44 p.m., CNA R said Resident #1 was totally dependent for mostly all of his ADLS. She said he usually stayed in bed and was not walking. Record review of the facility policy dated 2001 indicated Discharge Summary and Plan Policy StatementWhen a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge.Policy Interpretation and ImplementationThe discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's:current diagnosis;medical history (including any history of mental disorders and intellectual disabilities);course of illness, treatment and/or therapy since entering the facility;current laboratory, radiology, consultation, and diagnostic test results;physical and mental functional status;ability to perform activities of daily living including:bathing, dressing and grooming, transferring and ambulating, toilet use, eating, and using speech, language, and other communication systems;the need for staff assistance and assistive devices or equipment to maintain or improve functional abilities; andthe ability to form relationships, make decisions including health care decisions, and participate (to the extent physically able) in the day-to-day activities of the facility;sensory and physical impairments (neurological, or muscular deficits; for example, a decrease in vision and hearing, paralysis, and bladder incontinence);nutritional status and requirements including:weight and height;nutritional intake; andeating habits, preferences and dietary restrictions;special treatments or procedures (treatments and procedures that are not part of basic services provided);mental and psychosocial status (ability to deal with life, interpersonal relationships and goals, make health care decisions, and indicators of resident behavior and mood);discharge potential (the expectation of discharging the resident from the facility within the next three months);dental condition (the condition of the teeth, gums, and other structures of the oral cavity that may affect a resident's nutritional status, communications abilities, quality of life, and the need for and use of dentures or other dental appliances);activities potential (the ability and desire to take part in activity pursuits which maintain or improve physical, mental, and psychosocial well-being);rehabilitation potential (the ability to improve independence in functional status through restorative

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the status of the residents for 1 of 5 residents (Resident #1) reviewed for accuracy of assessment. The facility failed to accurately complete the MDS assessments to indicate Resident #1 required assistance with ADLs. This failure could place residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being.Findings included: Record review of Resident #1's face sheet dated 08/14/26 indicated he was a [AGE] year old male, admitted to the facility on [DATE], and his diagnoses included diffuse traumatic brain injury (happens when rapid rotation or shaking of the head causes the brain's connecting nerve fibers to stretch or tear), hypertension (high blood pressure), degenerative disease of the nervous system (nerve cells in the brain or spinal cord progressively lose structure, function, and eventually die), severe dementia with agitation (intense emotional distress, pacing, yelling, or physical aggression), seizures (sudden burst of abnormal electrical activity in the brain), encephalopathy (a general term for any disease, damage, or overall dysfunction of the brain), cognitive communication deficit (breakdown in communication caused by impaired thinking process), major depressive disorder (mental health condition), and generalized anxiety disorder (mental health condition). Record review of Resident #1's ADL Only Evaluation dated 02/05/26 indicated he was independent or required 1 person assist for bed mobility. He required supervision or required 1 person assist to transfer. He required supervision or set up for eating. He required one person assist to total dependence for toileting and personal hygiene. He required supervision or one person assist to walk in his room. He required one-person physical assist to total dependence for dressing. Record review of Resident #1's annual MDS assessment dated [DATE] indicated he was readmitted from hospital on [DATE]. He had unclear speech, sometimes could make himself understood and sometimes understood others. He had severe cognitive impairment. He was independent for eating. He required set up or clean-up assistance for upper and lower body dressing and putting on or taking off footwear. He required supervision or touching assistance for oral hygiene, toileting, shower/bath, and personal hygiene. He was independent to roll left and right, sit to lying, lying to sitting, sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, walk 10 feet, walk 50 ft with two turns and walk 150 feet. Record review of Resident #1's care plan dated 04/15/26 indicated he had an ADL self-care performance deficit related to dementia, impaired balance, and limited mobility. Interventions included total dependence on 1 staff for bath/shower, bed mobility, dressing, eating, personal hygiene, oral care, toilet use, and transfers. Record review of Resident #1's Functional Abilities IDT assessment dated [DATE], and completed by the DOR, indicated Resident #1 was independent for eating, required supervision or touching assistance for oral hygiene, toilet hygiene. He was independent to roll left and right, sit to lying, lying to sitting, sit to stand, char/bed to chair transfer, toilet transfer, tub/shower transfer, walk 10 feet, walk 50 feet with two turns, and walk 150 feet. Review of Resident #1's quarterly MDS assessment dated [DATE] indicated he had no speech, was sometimes able to make himself understood and sometimes understood others. He had severe cognitive impairment. He was always incontinent of bladder and bowel. He was independent for eating. He required set up or clean-up assistance for upper and lower body dressing and putting on or taking off footwear. He required supervision or touching assistance for oral hygiene, toileting, shower/bath, and personal hygiene. He was independent to roll left and right, sit to lying, lying to sitting, sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, walk 10 feet, walk 50 ft with two turns and walk 150 feet. Record review of Resident #1's discharge MDS dated [DATE] indicated he had severe cognitive impairment. He was independent for eating. He required set up or clean-up assistance for upper and lower body dressing and putting on or taking off footwear. He required supervision or touching assistance for oral hygiene, toileting, shower/bath, and personal hygiene. He was independent to roll left and right, sit to lying, lying to sitting, sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, walk 10 feet, walk 50 ft with two turns and walk 150 feet. During an interview on 08/14/26 at 1:30 p.m., CNA I said Resident #1 rarely got out of bed, was totally dependent for all care, including being fed. She said it was a slow decline and it was noted on the ADLs documentation. During an interview on 08/14/26 at 1:38 p.m., CNA J said Resident #1 was totally dependent for all care including dressing, shaving, oral hygiene, baths, nails, hair, and feeding. She said all ADLs were documented in ADLs of the task record on Resident #1's electronic record. During an interview on 08/14/26 at 1:43 p.m., TX LVN B said Resident #1 was totally dependent for all care. She said sometimes he would need assistance with feeding. She said he would sometimes nod his head yes or shake his head no but was non-verbal for communication. She said she had never heard him speak. During an interview on 08/14/26 at 2:25 p.m., the DOR said Resident #1 was dependent for ADLs when he discharged on 07/21/26. She said the functional abilities assessment completed on 05/04/26 was not accurate. She said she was not asked to re-assess Resident #1 for decline in ADLs. During an interview on 08/14/26 at 2:30 p.m., the DON said the facility had been through more than one MDS nurse and more than one MDS coordinator in the previous year. She said Resident #1's MDS was completed by the previous facility MDS Coordinator. She said she (the DON) signed the assessment as complete but did not realize the MDS was incorrect. She said the new MDS Coordinator would be auditing all MDS' for accuracy and submitting corrections as needed. She said the risk of incorrect MDS assessments could mean the residents did not receive the care or services they needed. During an interview on 08/14/26 at 2:37 p.m., the ADON said Resident #1's ADL documentation in the electronic system was not available for review after discharge due to a change and upgrade of the electronic system During an interview on 08/17/26 at 9:07 a.m., Owner E said she received Resident #1 from a nursing facility. She said she agreed to take Resident #1 to her facility but on the date he was discharged (07/21/26) from the facility, she did not have an open bed so she arranged for Resident #1 to go to another location. She said she was informed from (named hospital) that Resident #1 was able to do things for himself and could walk but chose not to walk. She said she was not aware he was dependent for care. During an interview on 08/18/26 at 8:19 a.m., Owner O said she did not receive clinical information from EMS transport. She said Family Member N said Resident #1 was able to care for himself and walk but he sometimes chose not to. She said she received Resident #1's hospital records dated 07/25/25 (from named hospital) from Owner E. She said Owner O said Resident #1 was walking and talking. She said Resident #1 declined after he was transferred to her facility on 07/21/26. She said she was trying to assist Family Member N to obtain alternate placement and resources. She said she would not have accepted Resident #1 had she known he required 100% care. Record review of the facility policy Compressive Assessments dated 2001 (revised March 2022) indicated Comprehensive assessments are conducted to assist in developing person-centered care plans. Policy Interpretation and Implementation 1. Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 8 resident rooms (room [ROOM NUMBER]) reviewed for environment. The facility failed to repair a missing closet door and replace torn/worn curtains in a timely manner in room [ROOM NUMBER] as of 07/23/26. The facility failed to ensure one closet was clean and free of spider webs, insect carcasses, and a ball shaped brown unknown substance in room [ROOM NUMBER] as of 07/23/26. These failures could place residents at risk of an uncomfortable environment and a decrease in quality of life and self-worth.Findings included:Observation on 07/23/26 at 9:05 a.m. indicated room [ROOM NUMBER] (on the secure unit) closet was missing a left side door. There was a large spider web visible in the back left corner. There were numerous bug carcasses in the spider web and on the floor. There was a brown ball shaped unknown substance, approximately 1.5 inches in diameter, on the closet floor adjacent to the spider web. There was unidentified clothing items on the floor of the closet. The patio door curtains were not properly hung on the rod (partially hanging off the rod) and 1 of 2 curtains were torn and missing the hem section.During an interview on 07/23/26 at 9:07 a.m., the Maintenance Supervisor said he was not aware of the missing door. He said the staff were supposed to write up maintenance issues on a log located at the nurse station and he would address/fix any issues.During an interview on 07/23/26 at 12:58 p.m., CNA A said the closet door in room [ROOM NUMBER] had been missing for quite a while. She said she did not know if any staff had documented the missing door. She said housekeeping issues were brought to the attention of the Housekeeping Supervisor.During an interview on 07/23/26 at 2:10 p.m., the Housekeeping Supervisor said the staff were supposed to clean the rooms, as necessary. She said she conducted look behind inspections and cleaned rooms and just missed that the closet was not cleaned. She said 3 rooms per day were supposed to be deep cleaned. She said room room [ROOM NUMBER] had not been deep cleaned in the current room clean rotation. She said cleaning rooms included sweeping. She said the cleaning list did not include the closets. She said all maintenance issues were documented on a log at the nurse station. She said she did not know if the missing closet door in room [ROOM NUMBER] was documented.During an interview on 07/24/26 at 9:53 a.m., the Administrator indicated her expectations were for all the facility areas to be clean and in good repair. She said she had been the Administrator for approximately one month. She said she was in the process of replacing all room curtains and conducting deep cleaning of all resident rooms. She said she was not aware of the missing closet door or the uncleanliness of the closet in room [ROOM NUMBER].Record review of the facility Maintenance log from May 2026 and June 2026 did not include the missing closet door or frayed curtain in room [ROOM NUMBER].Record review of maintenance log at the nurse station for July 2026 indicated there was no documentation of the missing closet door for room [ROOM NUMBER].Record review of the facility calendar for deep room clean indicated room [ROOM NUMBER] was deep cleaned on 07/15/26.Record review of an undated Resident Room Deep Cleaning Checklist provided by the Housekeeping Supervisor indicated there was no specific closet designation for check off.Record review of an undated Daily Resident Room Cleaning Checklist provided by the Housekeeping Supervisor indicated there was no specific closet designation for check off.Record review of the facility's undated Environment policy indicated Residents are provided with a safe, clean, and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation 1. Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean and sanitary environment; .During an interview on 07/24/26 at 9:53 a.m., the administrator was asked to provide a policy related to the maintenance or repairs of the facility. This policy was not provided by the administrator prior to exit.

Based on observations, interviews, and record review the facility failed to ensure residents received adequate supervision, to the extent possible for 1 of 3 residents that smoke on the secure unit (Resident #33), 3 of 3 residents (Residents #6, #9 & #14) of the general population that smoke and for 1 of 1 unoccupied resident room reviewed for safety. 1. The facility failed to ensure Resident #6, and Resident #14 did not smoke unsupervised within 25 feet of the flammable gas water heater. 2. The facility failed to ensure Resident #33's environment was free of hazards, on 4/13/26 Resident #33 was observed smoking outside on the secure unit patio area, there was no designated signage, no fire extinguisher, no fire blanket, no ash tray and no fire-safety can. 3. On 4/13/26 the facility failed to supervise Resident #9 while smoking. 4. The facility failed to ensure an unoccupied room was free of unsecured chemicals in spray bottles. These failures could place residents at risk for injury and burns. Findings included: Resident #14 Record review of a face sheet dated 04/13/2026 indicated Resident #14 was a [AGE] year-old female that was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident #14 had diagnoses of aphasia (is a language disorder commonly caused by cerebral infarction, affecting speech, comprehension, reading, and writing, with recovery influenced by lesion location and therapy.), dysarthria (is a speech disorder caused by muscle weakness that affects the ability to control the muscles used for speech, leading to slurred or slow speech that can be difficult to understand.), dysphagia (difficulty swallowing.), muscle wasting and atrophy (is the loss of muscle mass and strength.), right shoulder and right hand contracture (is a permanent shortening and tightening of muscle fibers that reduces flexibility and makes movement difficult.). Record review of Resident #14's quarterly MDS dated [DATE] indicated she used a wheelchair for mobility, and she had a BIMS of a 15 indicated she was cognitively intact. In section GG - Functional Abilities (GG0130. Self-Care) indicated that Resident #14 was dependent on staff for toileting, shower/bath, lower dressing, and maximal assistance for personal hygiene. Record review of Resident #14's care plan indicated: revision dated: 12/03/2025- Focus: Resident #14 is a smoker and is at risk for Injury. Resident #14 also uses a vape from time to time. Vape must also only be used per same smoking policy at specified times and under supervision. Goal: Resident will Adhere to the Tobacco/Smoking Policies of the Facility. Inventions: Conduct Smoking Safety Evaluation on admission and PRN. Revision dated: 08/26/2022. Educate Resident / Responsible Party on the facility's tobacco / smoking policy(s). Revision dated: 08/26/2022. Utilize cigarette holder. Revision dated: 07/19/2022. Focus: Resident #14 required assistance with ADLs related to aging and disease processes, weakness, contractures to right shoulder and hand. - revision dated- 01/07/2026. Goal: Resident #14 would be will be assisted with ADLs thru the next review date. – target date- 04/07/2026. Interventions: May apply resting hand splint to right hand. Date Initiated: 10/27/2025. During an observation and interview on 04/13/2026 at 01:32 p.m. indicated Resident #14 was seen in her motorized wheelchair smoking a cigarette, unsupervised, outside in an undesignated area that was located within 10 feet of the door that enclosed the water heater. A metal sign was posted on the door that reflected, No smoking within 25 feet of building entrance please do not throw butts on ground. Resident #14 had her cigarette close to her pants. Once she was finished with her cigarette, she flicked the un-extinguished cigarette onto the grass. Resident #14 said she kept her cigarettes with her and she was unable to say who lit her cigarette. She said she knew where she was smoking was not a designated smoking spot. She said sometimes she smoked by the door that enclosed the water heater when staff was not outside when she smoked. She said there was no staff outside with her when she was smoking on 04/13/2026 at 1:32 p.m. She said she forgot she could not smoke in undesignated smoking areas. During an observation and Interview on 04/14/2026 at 3:20 p.m., indicated CNA A showed the surveyor the box that held the residents cigarettes. Resident #14's cigarettes were not in the box. CNA A said Resident #14's cigarettes were not in the box, and she did not know where she had gotten her cigarettes from. She said staff was responsible for supervising the residents during smoke break till the last person is done. Resident #6 Record review of the admission record dated 04/15/2026 indicated Resident #6 was admitted on [DATE] and he was [AGE] years old. His diagnoses included end stage renal disease (kidney failure), heart disease, depression and anxiety. Record review of Resident #6's annual MDS assessment dated [DATE] indicated Resident #6 did not use tobacco. Resident #6 had a BIMS of 15 which indicated his cognition was intake. Record review of Resident #6's care plan dated 04/21/2025 indicated Resident #6 was a tobacco smoker and was at risk for injury. The approaches included to explain/show where designated smoking areas are and smoking times – repeat as needed. Keep smoking material at nurses' station. Perform smoking assessment according to facility policy. Record review of Resident #6's smoking assessment dated [DATE] indicated Resident #6 did use tobacco and required supervision. During an observation and interview on 04/13/2026 at 01:32 p.m., revealed Resident #6 was seen in his wheelchair smoking a cigarette unsupervised, outside in an undesignated area that was located approximately within 10 feet of the door that enclosed the water heater. A metal sign was posted on the door that reflected, No smoking within 25 feet of building entrance please do not throw butts on ground. Once Resident #6 was finished with his cigarette, he flicked the un-extinguished cigarette onto the grass. Resident #6 said he kept his cigarettes with him and was unable to say who lit his cigarette. He said he knew where he was smoking was not a designated smoking spot. He said he had smoked in the undesignated spot by the sign more than once without staff moving him. He said there was no staff outside with him when he was smoking on 04/13/2026 at 1:32 p.m. Record review of the Smoking Policy – Residents Policy last revised [DATE] indicated: Policy Statement: This facility has established and maintains safe resident smoking practices. Policy Interpretation and Implementation: Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Smoking is not allowed inside the facility under any circumstances. Ashtrays are emptied only into designated receptacles. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: current level of tobacco consumption. method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.); desire to quit smoking; and ability to smoke safely with or without supervision (per completed Safe Smoking Evaluation). The staff consults with the attending physician and the director of nursing services (DNS) to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. A resident's ability to smoke safely is re-evaluated quarterly, upon significant change (physical or cognitive) and as determined by the staff. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the residents shall be alerted to these issues. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker always while smoking. All smoking materials to include cigarettes/cigars/e-cigarettes/vapes, lighters, and matches, are to be maintained by the nursing department and are prohibited to be maintained in a resident's room or person. Residents are not permitted to give smoking items to other residents. Residents will follow the facility smoking schedule and facility staff will ensure that resident smoke schedule is adhered to unless there are special circumstances preventing the schedule to be followed (special circumstances include but are not limited to weather conditions, and any other condition determined to be a health issue to the residents). 2. Resident #33 Record review of Resident #33's face sheet dated 04/13/2026 indicated he was a [AGE] year-old-male admitted [DATE] with diagnoses of bipolar disorder (mental health condition characterized by extreme mood swings emotional highs and lows) and seizures (convulsions). Record review of Resident #33's Smoking assessment dated [DATE] indicated he required supervision during designed smoking times. Record review of Resident #33's most recent Annual MDS assessment dated [DATE] indicated he had a BIMS score of 00 which indicated cognition severely impaired, had unclear speech, usually understood and had clear comprehension. Record review of Resident #33's care plan with a target date of 06/23/26 indicated he was a smoker at risk for injury with interventions including explain/show where designated smoking areas are and smoking times and resident will be supervised during smoking times. During an initial tour observation 04/13/26 at 9:35 a.m, of the secure unit patio area revealed 25-50 cigarette butts approximately 1-2 feet away from a large pile of dry leaves and the patio doors entrance. There were no ash trays, no fire cans, no signs indicating a designated smoking area, no fire extinguisher and no fire blanket. During an interview on 04/13/26 at 11:35 a.m., LVN O said she was the licensed nurse working on the secure unit. LVN O said residents smoked in the patio area and the residents are always supervised during smoking. LVN O said if there was a fire in the secure smoking area she would have to use the fire extinguisher inside on the hall because there was not one in the secure unit smoking area. LVN O said there were no ash trays or signage in the secure unit smoking area. LVN O said there would be a delay in putting out a fire in the secure unit smoking area because a fire extinguisher was not readily available there on the patio. LVN O said residents put out their cigarettes by stepping on them on the ground. LVN O said putting out cigarettes on the ground increased the risk of residents on the secure unit picking them up. During an interview on 04/13/26 at 11:45 a.m., CNA X said she was the nursing assistant working on the secure unit. CNA X said residents always smoked their cigarettes on the secure patio area since she had worked for the facility and she said she started November 2025. CNA X said she had taken Resident #33 out to smoke this morning on the secure unit patio and there was no fire extinguisher. She said she didn't know where she would get a fire extinguisher if she needed one. CNA X said there were no ash trays and residents put their cigarettes out by stepping on them. CNA X said not having the extinguisher or fire blanket could delay putting out a fire in the secure unit smoking area. During an observation and interview on 04/13/2026 at 12:00 p.m., the Maintenance Director said the secure unit patio was not a designated smoking area and that was why there were no fire extinguishers, no fire blankets, no designated smoking signage or ash trays. The Maintenance Director said residents on the secure unit were to smoke cigarettes with the other residents in the general population in the designated smoking area. The Maintenance Director said there were probably 50 or more cigarette butts on the ground and approximately 1-2 feet away from the dry leaves which could possibly start a fire if a cigarette was not put out properly. The Maintenance Director said the risk of not smoking in the designated smoking area could cause a fire and delay in putting out a fire. During an observation and interview on 04/13/26 at 1:30 p.m. revealed Resident #33 spoke with incomprehensible sounds. RN P was supervising Resident #33 outside on the secure unit patio smoking a cigarette in the undesignated smoking area. RN P said the area was where the residents who smoked on the secure unit were allowed to smoke. RN P said there was no fire extinguisher, no fire blanket and no ash trays that was why she was allowing Resident #33 to put his ashes in a cup of water and not on the ground to avoid a fire. RN P said the Maintenance Director had swept up the cigarette butts from the patio ground and she was not aware of the area not being a designated smoking area. During an interview on 04/13/2026 at 2:45 p.m. the DON said she was not aware that residents were outside smoking in an undesignated spot on the secure unit. She said smoking was an ongoing issue that administration had addressed. She said residents and staff were in-serviced on where to smoke, time, and supervision and the equipment needed to be a designated smoking area and no one should be putting their cigarettes out by stepping on them could cause a fire. The DON said a fire extinguisher was needed in the area of smoking for quick access in the event of a fire. During an observation on 04/14/26 at 9:00 a.m., revealed on the secure unit patio there was a sign which indicated designated smoking, fire extinguisher, fire blanket, ash tray and fire can. 3.Resident #9 Record review of Resident #9's face sheet dated 04/13/2026 indicated he was a [AGE] year-old-male admitted [DATE] with diagnoses of cerebral infarction (a type a stroke caused blockage in the brain blood vessels cutting off oxygen and leading to brain tissue death) and hemiplegia (total or partial paralysis of one side of the body that results from disease or injury to the motor centers of the brain) and hemiparesis (partial weakness or slight paralysis affecting only one side of the body) of the right side. Record review of Resident #9's Smoking Safety Evaluation dated 02/21/2026 indicated Resident#9 required supervision during designed smoking times. Record review of Resident #9's most recent Annual MDS assessment dated [DATE] indicated he had a BIMS score of 13 which indicated intact cognition, current use of tobacco and diagnoses of cerebral infarction, hemiplegia and hemiparesis. Record review of Resident #9's care plan with a target date of 06/17/2026 indicated he was a smoker at risk for injury with interventions including keeping smoking materials at the nurse station and observe prn when smoking to assure resident's safety. During an observation and interview on 04/13/2026 at 2:15 p.m. indicated Resident #9 was outside smoking a cigarette in the designated smoking area under the car port with no staff present. He said it was his choice to keep his cigarettes in his own possession He said he did not keep a lighter in his possession. Resident #9 declined telling who lit his cigarette. During an interview on 04/14/2026 at 1:45 p.m. the DON said she was not aware that Resident #14 was outside smoking in an undesignated spot, nor was she aware residents were flicking their lit cigarettes onto the grass with 25- feet of the water heater. She said smoking was an ongoing issue that administration had addressed. She said residents and staff were in-serviced on where to smoke, time, and supervision. She said residents were made aware that staff must keep their smoking supplies unless stated otherwise. She said the residents were informed verbally that they could not keep smoking supplies on them. During an observation and interview on 04/13/2026 at 4:00 p.m., indicated there was a sign which indicated No Smoking Within 25 Feet (on the outside of the door containing the water heater) and the Maintenance Director said he had placed the sign there because the gas hot water heater was behind the door. He said if the pilot light went out and if someone was smoking too close to the hot water heater that could cause a fire. He said all the residents and staff were informed within the last 2 years about not smoking there. During an interview on 04/13/2026 at 4:45 p.m., the DM said the dietary department was responsible for the 1:30 p.m. smoking time daily and the dietary staff sometimes helped smoke the residents at 8:30 a.m. smoking time. She said [NAME] B was responsible for smoking the residents during the 1:30 p.m. smoking time on 04/13/2026. She said the dietary staff were educated to gather the smoking residents' smoking supplies from the nurse station and monitor the residents during the whole smoking time. The DM said [NAME] B smoked so she stayed the whole smoking time and smoked with the smoking residents. The DM said the smoking residents were smoked under the carport by the end of the secured unit, the designated smoking area. She said the facility had recently had a meeting with the smokers about not smoking alone but was unsure of the date. The DM said she had never seen residents smoking by themselves without supervision. During an interview on 04/13/2026 at 4:58 p.m., [NAME] B said she smoked the residents on 04/13/2026 during the 1:30 p.m., smoking time. She said she started the residents smoking about 1:30 p.m., including Residents #6, #9 and #14. [NAME] B said no residents were smoking before she arrived at the smoking area with the cigarette box. She said all residents had cigarettes in the box except Resident #9. [NAME] B said she had been educated on smoking the residents and monitoring the complete smoking time. She said she had not seen residents smoking without supervision. [NAME] B said the residents were only smoked under the car port behind the secured unit in the designated smoking area. 4. During an observation on 04/13/2026 at 9:30 a.m., revealed unoccupied room [ROOM NUMBER] had a closed for repairs sign on the door, however the door was unlocked. Inside the room was a maintenance cart and hanging on the attached trash receptacle were 2 spray bottles, 1 marked as 10 % bleach and the other had no markings. There were no staff or residents within sight of the door. During an observation and interview on 04/13/2026 at 9:35 a.m., LVN C said the chemicals should be locked and secured to prevent residents from having access. She notified the Maintenance Director. She said there were residents on this hall that have dementia and were confused. During an observation and interview on 04/13/2026 at 9:38 a.m., the Maintenance Director walked into room [ROOM NUMBER] and said the room was closed for repairs. He said the one unmarked bottle was diluted oven cleaner. He said all chemicals should be secured and locked when not in use or within sight of staff to prevent injuries. He immediately marked the bottle and locked the chemicals in the cart.

Based on interview and record review the facility failed to ensure they had an RN for 8 consecutive hours 7 days a week for 1 of 3 months reviewed for RN coverage. The facility did not have 8 hours of RN coverage on 12/13/2025, 12/14/2025, 12/20/2025, 12/21/2025, 12/27/2025, and 12/28/2025.This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as emergency care and disasters.Findings included: During an interview on 04/15/2026 at 11:15 a.m., the HR said the corporate submitted to the PBJ, however she would pull the sign in sheets and time sheets for the dates 12/13/2025, 12/14/2025, 12/20/2025, 12/21/2025, 12/27/2025, and 12/28/2025. She said those dates were the weekend coverage for the month of December 2025. During an interview on 04/15/2026 at 12:01 p.m., the HR said there were only 2 RNs during that period, and they were not covering the weekends. Record review of the RN time sheets for December 2025 indicated:* no RN coverage for the dates of 12/13/2025, 12/14/2025, 12/20/2025, 12/21/2025, 12/27/2025, and 12/28/2025.During an interview on 04/15/2026 at 12:15 p.m. the DON said she came to work at the facility in January 2026, so she was unaware if they had RN coverage for 7 days a week in December 2025. The weekend RNs would supervise patient care and ensure residents would receive nursing services. During an interview on 04/15/2026 at 02:52 p.m. the Administrator said he was new however his expectation was for an RN on duty 8 hours a day every day. He said the RN on the weekends would supervise nursing department.

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions for 1 of 1 kitchen reviewed for food served under sanitary conditions. The facility failed to ensure the ham (approximately 10-inch by 4-inches) was stored in the refrigerator, covered and on a clean surface. The facility failed to ensure the deep fryer did not have dark cooking oil and was free of thick black buildup of grease and burnt food particles around to top of the deep fryer. The facility failed to ensure the kitchen hallway were free of a trash can with trash piled 3 feet above the can and on the floor approximately 3 feet around the trash can. These failures could place residents at risk for food contamination, food borne illness and a diminished quality of life. The findings included:During observations and interviews on 04/13/2026 at 8:30 a.m., revealed an uncovered piece of ham approximately 10-inch by 4-inches, half of it touching a prep table with food particles and pieces of the paper that had covered the ham. The DM said the ham should not have been left out of the refrigerator and uncovered, to prevent food born illness. The deep fryer contained cooking oil that was brownish black and had thick black buildup of burnt grease and food particles around the top of the deep fryer. She said the cooking oil was changed out weekly and as needed. She said sometimes thick burnt on food particles did not always come off. Further observation revealed there was a hallway in the kitchen by the dry storage room. In the hallway was a 64-gallon rolling trash can. There were bags of garbage and empty boxes on top of the rolling trash can that extended approximately 3 feet above the open trash can. Around the garbage can was garbage and empty boxes on the floor. The DM said the garbage should have been taken out before running over in the hallway. The DM said the kitchen should be kept clean and free of garbage to prevent food born illnesses and prevent pest issues. Record review of the FDA code dated April 2022 indicated .Proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be a possible source of contamination of food, equipment, and utensils. Storage areas for garbage and refuse containers must be constructed so that they can be thoroughly cleaned in order to avoid creating an attractant or harborage for insects or rodents. In addition, such storage areas must be large enough to accommodate all the containers necessitated by the operation in order to prevent scattering of the garbage and refuse. All containers must be maintained in good repair and cleaned as necessary in order to store garbage and refuse under sanitary conditions as well as to prevent the breeding of flies. Garbage containers should be available wherever garbage is generated to aid in the proper disposal of refuse.Foodborne illness may result from ready-to-eat food being held at unsafe temperatures for long periods of time due to the outgrowth of bacteria.Assessing Contaminated Equipment and Potential for Cross- Contamination This risk factor involves the proper storage and use of food products and equipment to prevent cross-contamination. The cleaning, sanitization, and storage of food-contact surfaces of equipment and utensils in a manner to prevent transmission of foodborne pathogens or contamination is also included in this risk factor.(6) The cleaning schedule is APPROVED based on consideration of: (a) Characteristics of the equipment and its use, (b) The type of food involved, (c) The amount of food residue accumulation, and (d) The temperature at which the food is maintained during the operation and the potential for the rapid and progressive multiplication of pathogenic or toxigenic microorganisms that are capable of causing foodborne disease;.

Based on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety that also consider non-smoking residents for 1 of 2 smoking areas (main smoking area under the car port) reviewed for smoking safety. The facility failed to ensure paper and plastic trash were not discarded into the fire safety cans on 04/13/26. This failure could place residents at risk of injury, burns, and an unsafe smoking environment. Findings included: During an observation and interview on 04/13/26 at 12:20 p.m. revealed the two red fire cans in the main designated smoking area, under the car port, contained cigarette butts, empty cigarette paper boxes, empty soda cans, chip bags, plastic and paper trash. The Maintenance Director emptied the trash out of both fire cans and said everyone was responsible for the smoking area and was unsure who would have put the trash in the fire cans, but if he had to guess, he said the trash was probably placed by other staff and residents. The Maintenance Director said he was responsible for maintaining the smoking areas which included emptying the red fire cans. He said he had done it this morning but would schedule rounding more frequently. The Maintenance Director said the red fire cans should only have cigarette butts because otherwise, it could be a fire hazard. During an interview on 04/13/2025 at 4:00 pm the DON said that the designated smoking areas were to be maintained by the Maintenance Director but all staff that assisted the residents to smoke should be mindful of the ashtrays and fire cans and ensure there was no trash in the red fire can. She said she would see to it that the staff was re-trained on the smoking policy and maintenance of the smoking areas. She said that by not maintaining the smoking area fires could happen. Record review of facility policy titled, Smoking Policy-Resident dated 2001 indicated, . This facility has established and maintains safe resident smoking practices. 5.Metal containers, with self-closing cover devices, are available in smoking areas. 6.Ashtrays are emptied only into designated receptacles.

Based on observation, interview and record review the facility failed to ensure the nurse call system was accessible for 1 of 6 (Resident #30) reviewed for resident call system. The facility failed to ensure Resident #30'a call light was within reach after her incontinent care was finished on 04/13/2026. This failure could place the residents at risk of not being able to directly contact the staff to obtain assistance for activities of daily living or help in an event of an emergency.Findings included: Record review of Resident #30's face sheet dated 04/14/2026 revealed a [AGE] year-old female with admission date of 03/20/2026. Diagnoses included metabolic encephalopathy (a brain dysfunction caused by systemic metabolic disturbances, leading to confusion, memory loss.) type 2 diabetes (high levels of sugar in the blood), essential primary hypertension (high blood pressure), immunodeficiency (condition in which the immune system is weakened or absent, reducing the body's ability to fight infections and abnormal cells).Record review of Resident #30's admission MDS assessment dated [DATE] indicated a BIMS score of 10 which indicated moderate cognitive impairment. Section GG- Functional Abilities indicated she was dependent and required 2 or more staff members was for mobility and self-care needs.Record review of Resident #30's baseline care plan dated 03/20/2026 indicated she was dependent on staff members for mobility and self- care needs.During an observation and interview on 04/13/2026 at 9:45 a.m., indicated CNA Z was changing Resident #30's brief with the assistance of LVN C. After Resident #30 was changed, CNA Z and LVN C did not place her call light within reach. Resident #30's call light was behind her roommate's dresser approximately 10 ft from her. During an interview with Resident #30, she said she knew what the purpose of a call light was. She said she had used the call light before but could not say how long she had been without it. She said to get staffs attention she yelled if the call light was not in her reach. She said she wanted the call light in her hand so she could call for help. During an interview on 04/13/2026 at 10:05 a.m., CNA Z said she forgot to give Resident #30 the call light before she left out the room. She said she was unaware how long Resident #30 was without her call light in reach. She said it was the responsibility of every staff member that entered the room to ensure she had her call light within reach. She said the potential risk was Resident #30 not having access to staff if she needed help.During an interview with LVN C on 04/13/2026 at 10:15 a.m., she said she had not placed Resident #30's call light within her reach before leaving her room. She said she had forgotten to place it in Resident #30's hand before leaving her room. She said it was the responsibility of every staff member that entered the room to ensure she had her call light within reach. She said the potential risk was Resident #30 not having access to staff if she needed help.During an interview with the DON on 04/13/2026 at 1:00 p.m., she said she expected all staff members to ensure the residents had their call lights within reach to ensure they had access to staff. She said it was the responsibility of every staff member that entered the room to ensure residents had their call lights within reach. She said the potential risk was Resident #30 not having access to staff if she needed help. Record review of the facility's policy titled Call System, Residents undated, indicated: Policy StatementResidents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation.Policy Interpretation and Implementation1. 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.8. The call system will be in reach of each resident at the resident's preference.

Based on observation, interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 20 residents (Resident #6) reviewed for MDS assessment accuracy.The facility incorrectly coded Resident #6's annual MDS assessment dated [DATE] as not using tobacco when he did use tobacco.This failure could place residents at risk for not receiving care and services to meet their needs. Findings include:Record review of Resident #6's admission record dated 04/15/2026 indicated Resident #6 was admitted on [DATE] and he was [AGE] years old. His diagnoses included end stage renal disease (kidney failure), heart disease, depression and anxiety.Record review of Resident #6's smoking assessment dated [DATE] indicated Resident #6 used tobacco and required supervision.Record review of the annual MDS assessment dated [DATE] indicated Resident #6 did not use tobacco.Record review of Resident #6's care plan dated 04/21/2025 indicated Resident #6 was a tobacco smoker and was at risk for injury. The approaches included to explain/show where designated smoking areas are and smoking times - repeat as needed. Keep smoking material at nurses' station. Perform smoking assessment according to facility policy.During an observation on 04/14/2026 at 1:30 p.m., revealed Resident #6 was in the smoking area and was being supervised while smoking.During an interview on 04/15/2026 at 11:02 a.m., the MDS Nurse said she must have miscoded Resident #6's annual MDS assessment. She said the facility used the RAI manual for the instructions and their policy. She said if MDS was not correct the residents could not get care and services needed.During an interview on 04/15/2026 at 11:30 a.m., the DON said her expectation was for the MDS assessment to be accurate and they used the RAI manual for the instructions and their policy.Record review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1 October 2024 indicated . Section J1300: Current Tobacco Use Item Rationale Health-related Quality of Life. The negative effects of smoking can shorten life expectancy and create health problems that interfere with daily activities and adversely affect quality of life. Planning for Care This item opens the door to negotiation of a plan of care with the resident that includes support for smoking cessation. If cessation is declined, a care plan that allows safe and environmental accommodation of resident preferences is needed.Steps for Assessment 1. Ask the resident if they used tobacco in any form during the 7-day look-back period.2. If the resident states that they used tobacco in some form during the 7-day look-back period, code 1, yes.DEFINITION TOBACCO USE: Includes tobacco used in any form.

Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 3 residents (Resident #30) reviewed for baseline care plan. The facility failed to revise Resident 30's baseline care plan included her g-tube This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included: Record review of Resident #30's face sheet dated 04/14/2026 revealed a [AGE] year-old female with admission date of 03/20/2026. Diagnoses included metabolic encephalopathy (a brain dysfunction caused by systemic metabolic disturbances, leading to confusion, memory loss), dysphagia ( difficulty swallowing), immunodeficiency (condition in which the immune system is weakened or absent, reducing the body's ability to fight infections and abnormal cells). Record review of Resident #30's admission MDS assessment dated [DATE] indicated a BIMS score of 10 which indicated moderate cognitive impairment. In Section K - Swallowing/Nutritional Status indicated she had a feeding tube. Record review of Resident #30's baseline care plan dated 03/20/2026 indicated she did not have feeding tube (g-tube: a medical device inserted through the abdomen to deliver nutrition, fluids, and medications directly into the stomach when oral intake is insufficient.) Record review of Resident #30's Care Plan history on 03/31/2026 revealed Resident #30's next review date for her care plan was 03/27/2026 indicating it was 18 days overdue. During an interview with the MDS Nurse on 04/14/2026 at 12:45 p.m., the MDS Nurse said she overlooked adding the g- tube to Resident #30's care plan and that it should have been listed. She said the interdisciplinary team provided input into the care plan but ultimately it was her responsibility to complete the baseline care plan once the assessment was completed. The MDS Nurse said a delay in completing a baseline care plan could lead to nurses not being up to date on how to properly care for a resident. During an interview with the DON on 04/14/2026 at 1:00 p.m., she said the baseline care plan contained everything a nurse needed to know to care for a resident such as ADL's, medications, diet, treatments, goals, and interventions. The DON said it was important for the baseline care plan to be completed on time so all nurses would have the pertinent information needed to care for a resident. The DON said the care plan was insufficient due to the g-tube (not being included. Record review of the facility policy Care Plans, Acute and Comprehensive Person-Centered undated indicated: Policy Statement A acute/comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Policy Interpretation and ImplementationThe interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.Acute care plans are developed with the interdisciplinary team (IDT) for changes of condition, risk management and are reviewed as needed for updates or resolution.The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to:participate in the planning process.identify individuals or roles to be included.request meetings.request revisions to the care plan.participate in establishing the expected goals and outcomes of care.participate in determining the type, amount, frequency and duration of care.receive the services and/or items included in the plan of care; andsee the care plan and sign it after significant changes are made.The comprehensive, person-centered care plan:includes measurable objectives and timeframes.describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including:services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment.any specialized services to be provided as a result of PASARR recommendations; andwhich professional services are responsible for each element of care.includes the resident's stated goals upon admission and desired outcomes.builds on the residents' strengths; andreflects currently recognized standards of practice for problem areas and conditions.

Based on interview and record review, the facility failed to ensure residents were given the appropriate treatment and services to maintain or improve his or her ability to carry out activities of daily living (ADLs) to maintain good personal hygiene, for 1 of 3 residents (Resident #30) reviewed for ADLs. The facility failed to ensure Resident #30 was provided with a shower on 04/08/2026, 04/10/2026, and 04/13/2026. This failure could place residents at risk of not receiving care and services needed to maintain quality of life and prevent decline in their mental and psychological well-being. Findings included: Record review of Resident #30's face sheet dated 04/14/2026 revealed a [AGE] year-old female with admission date of 03/20/2026. Diagnoses included metabolic encephalopathy (a brain dysfunction caused by systemic metabolic disturbances, leading to confusion, memory loss.) type 2 diabetes (high levels of sugar in the blood), essential primary hypertension (high blood pressure), immunodeficiency (condition in which the immune system is weakened or absent, reducing the body's ability to fight infections and abnormal cells).Record review of Resident #30's admission MDS assessment dated [DATE] indicated a BIMS score of 10 which indicated moderate cognitive impairment Section E- Behavior indicated she did not exhibit any behaviors of rejecting ADL assistance. Section GG- Functional Abilities indicated she was dependent and needed 2 or more staff members for showering/ bathing. Record review of Resident #30's Shower/ADLs log dated 04/06/2026 indicated her last bed bath was 04/06/2026. Resident #30 had no documentation of a shower between 04/08/2026 through 04/13/2026. During an observation on 04/13/2026 at 9:45 a.m., indicated CNA Z was changing Resident #30's brief with the assistance of LVN C. A foul odor not related to the wet brief was noted in the room after Resident #30's urine brief was removed. She had white colored skin flakes around her mouth, cheeks, and forehead. Resident #30's hair appeared greasy and uncombed. During an interview on 04/13/2026 at 10:00 a.m., Resident #30 said that the staff did not take her to the shower room instead she received bed baths by her choice. She said she went without a bed bath for multiple days and did not know why. She stated she was not offered an alternative day to have a bed bath. She said she did not report this to nursing; but wanted to be cleaned. She said she noticed the smell in her room. She said she expected to get a bed bath every other day, and it was not provided. During an interview on 04/13/2026 at 10:00 a.m., CNA Z said she smelled the odor coming from Resident #30's body. She said hygiene wipes did not remove Resident #30's odor, instead soap and water had to be used. She said she was not aware when Resident #30 last had a bed bath. She said she would get a bed bath after her lunch meal. She said Resident #30 had not refused and was compliant overall with care. She said it was her responsibility to ensure Resident #30 received a shower/ bed bath, and it was her responsibility to report to the nurse if it was not possible. She said the potential risk was infection if residents were not routinely showered/ bathed. During an interview with the DON on 04/13/2026 at 4:00 p.m., she said it was her expectation for Resident #30 to be offered and given a shower or bed bath if she wanted one on her assigned days and as needed. She said it was CNA Z's responsibility to shower/ give a bed bath to Resident #30 when she smelled the strong odor coming from her body. She said she wanted residents to be offered showers or bed baths to ensure resident rights were honored. The DON said it was her responsibility to oversee that residents received ADL care, but she was not told by CNA Z that she had not given Resident #30 a bed bath on 04/13/2026. She stated she was aware of the issue and would provide in-service to CNA Z on showers/ bed baths for residents. During an interview with the Administrator on 04/15/2026 at 3:05 p.m., he said he expected the CNAs to provide showers/ bed baths and ADL care to residents on their assigned days. He said the CNAs need to coordinate with other staff to ensure the showers/ bed baths are completed. He said it was the DON's responsibility to oversee residents received their ADL care because it was important for resident rights to receive hygiene care. Record review of the facility's policy titles Resident Shower/Baths undated, provided by the VP of clinical compliance and the DON and signed by the DON indicated: Purpose:To ensure safe, dignified, and effective assistance with showering and bathing for residents while promoting resident independence, comfort and infection prevention.Policy: Residents may bathe or shower according to their preferences with appropriate supervision and minimal assistance to ensure safety, comfort, and dignity.Resident shower schedules will be scheduled per the resident preference. The facility bathe/shower schedules are Monday, Wednesday, Friday or Tuesday, Thursday, Saturday. If at any time the resident prefers a different schedule to include time of day the facility will try to accommodate the residents' wishes.The residents' privacy will be honored during bathes/showersInfection control processes will be observedResidents may choose not to shower, and the resident choice will be documented in the resident and reported to the charge nurse. The residents responsible party will be notified of the residents' refusal.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for 4 residents of 14 sampled reviewed for the environment. The facility did not maintain an effective pest control program to ensure the Resident #6 and Resident #34's room was free of gnats and flies. The facility did not maintain an effective pest control program to ensure Resident #23 and Resident #45's room was free of roaches. The failures could place residents at risk of potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life. Findings included: 1. Record review of Resident #6 's admission record dated 04/15/2026 indicated Resident #6 was admitted on [DATE] and he was [AGE] years old. His diagnoses included end stage renal disease, heart disease, depression and anxiety. Record review of Resident #6 annual MDS assessment dated [DATE] indicated Resident #6 BIMS score was a 15 which indicated his cognition was intact. Record review of Resident #34's admission record dated 04/15/2026 indicated Resident #34 was admitted on [DATE] and he was [AGE] years old. His diagnoses included epilepsy (chronic neurological disorder with seizures), and bipolar (chronic mental health condition with intense mood swings). Record review of Resident #34's annual MDS assessment dated [DATE] indicated Resident #34 BIMS score was a 09 which indicated moderate cognitive impairment. During an observation on 04/13/2026 at 12:27 p.m., revealed there were gnats and flies in the room for Resident #6 and Resident #34. There were 4 flies landing on Resident #34's bed which was unoccupied and clean. Further observation revealed there was a swarm of gnats (approximately 40 to 50 gnats) coming out of his garbage can. During interviews on 04/13/26 at 1:00 p.m., Resident #6 and Resident #34 both said they wanted the bugs to be gone. During an interview and observation on 04/14/2026 at 930 a.m., LVN C said yes, they had problems with flies and gnats as the surveyor and nurse observed Resident #6 and Resident #34 Room. The room had gnats and 2 flies, and LVN C said they needed to spray this room. She stated, I will put this room on the pest control's list. During an interview and record review on 04/14/2026 at 10:05 a.m., the maintenance director said the staff should have placed the room number on the pest control log and the staff did not. During an interview on 04/15/2026 at 3:00 p.m., the Administrator said he wanted the facility not to have pests. He said they had found the source was a refrigerator and they had started cleaning process. Record review of the pest log dated 11/04/2025 to 04/11/2026 revealed there were 2 reports of flies and gnats in other rooms last year. Residents #23 and #45 Record review of Resident #23's face sheet dated 04/13/2026 indicated a [AGE] year-old male admitted on [DATE] with diagnosis of essential hypertension (high blood pressure) and hyperlipidemia (high cholesterol). Record review of Resident #23's quarterly MDS assessment, dated 02/23/26, indicated a BIMS score of 14 indicating Resident #23 was cognitively intact. Record review of Resident #45's face sheet dated 04/13/2026 indicated a [AGE] year-old male admitted on [DATE] with diagnosis of essential hypertension (high blood pressure) and hyperlipidemia (high cholesterol). Record review of Resident #45's quarterly MDS assessment, dated 02/20/26, indicated a BIMS score of 13 indicating Resident #45 was cognitively intact. During an interview and observation on 04/13/2026 at 8:20 a.m., with Residents #23 and #45 in their room, revealed there was a large live cockroach running aimlessly in the room from Resident #23's side of the bed to Resident #45's side of the room and up under the side of his dresser. While interviewing Resident #23 and #45, Surveyor observed 3 other live roaches.(one moving across the floor from Resident #23 bed to the bathroom and two roaches crawling on the wall between both Resident's beds). Resident #23 said the roaches came from the outside and he was tired of the roaches in his room. Resident #45 said he did not have roaches in his bed and that maintenance was aware of roaches in the room. Residents #23 and #45 both said their room was sprayed for roaches about 2-3 weeks ago but they just kept coming back. During an interview on 04/13/26 at 8:30 a.m., LVN N said she saw the roaches and would get the Maintenance Director to spray Resident #23's and #45's room for the roaches. LVN N said the roaches most likely were coming from the outside. LVN N said when the bugs were noticed in the facility staff were to log it in the maintenance book at the nurse's station. LVN N said the facility was sprayed for bugs and flies about 2 weeks ago and had not seen any live bugs until today. LVN N said having bugs in the residents' room could cause them to be depressed. During an interview on 04/13/26 at 8:30 a.m. the DON said her expectations were for the facility to be bug free but that was not realistic because some residents ate in their room and some bugs came from the outside. The DON said staff were to log the rooms needing to be sprayed for bugs in the maintenance log book located at the station. She said Residents #23's and #45's room was just logged on 4/13/26 and the Maintenance Director was to call the pest control back out for service. During an interview and record review on 04/14/2026 at 8:35 a.m., the Maintenance Director said the staff usually logged in the maintenance book when and what room they observed bugs and he checked the book daily. The Maintenance Director said Residents #23 and #45 sometimes ate in their room which could cause roaches. The Maintenance Director said he spot sprayed their room yesterday when he was notified about it and did not see any roaches. The Maintenance Director said he had also called the pest control to come and service the building. Record review of the maintenance book indicated 03/08/26 was the previous log of roaches noticed in the facility.

Based on observations, interviews, and record review the facility failed to ensure the residents had the right to be free from abuse for 1 of 7 (Resident #1) residents reviewed for abuse. The facility failed to ensure Resident #1 was free from physical abuse by CNA B. The non-compliance was identified as PNC. The IJ began on 03/05/26 and ended on 03/13/26. The facility had corrected the non-compliance before the survey began. This failure could place residents at risk for abuse/neglect, humiliation, intimidation, fear, shame, agitation, and decreased quality of life.Findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included dementia (decline in mental ability), anxiety disorder, and Alzheimer's disease (progressive, irreversible neurological disorder that shrinks the brain and kills brain cells). Record review of Resident #1's MDS Resident Assessment and Care Screening form dated 02/04/26 revealed under Cognitive Patterns, Should brief interview of mental status be conducted? .0. No (resident is rarely/never understood) . Record review of Resident #1's care plan, admission date on 02/17/26, indicated Resident #1 has impaired cognition and is at risk for further decline and injury.BIMS score: 3.0 (severely cognitively impaired), dx of Alzheimer's Disease, Dementia, Anxiety Disorder.needs will be met and dignity maintained over the next 90 days. Record review of the Provider Investigation Report, dated 03/05/26, indicated, Investigation revealed that a CNA told a nurse that another CNA abused a resident while providing care. Employee was removed from the facility. Suspended (then terminated) pending investigation. MD, psych NP, and RP were all notified. Police Department notified case # [number]. Safe surveys completed with no adverse findings. Skin sweep completed with no adverse findings. Resident assessed for physical and psychosocial harm. Nothing noted. Conducted interview with resident and resident could not recall any issues with any staff members. Resident appears to be at baseline for cognition. Employee interviewed and denied. Resident remains stable .inservice on abuse/neglect.care plan updated.assessed resident with no adverse findings.psychosocial screening. Resident showed no signs of emotional distress, pain or any delayed injuries. Record review of CNA A's handwritten statement, dated 03/05/26, indicated CNA A 03/05/26.at 9:30 (p.m.) me and CNA B attempted/asked Resident #1 if he would like to be change, he refused, I asked again, he refused again. When I started to grab the belongings and leave, CNA B try to force him [Resident #1] to the bed Resident #1 started to get a little aggressive and CNA B started to get aggressive back, he first started by manhandling him and try to force him to the bed, once he was finally able to force him into the bed, Resident #1 began trying to push CNA B off him that's when CNA B hit Resident #1 on the arms around 3/4 times, then he grabbed both of Resident #1's hand pinned them down and started forcing his shorts down, he ripped Resident #1's brief off and just had him laying on the bed with nothing on his bottom, once he realized Resident #1 wasn't going to let him change him he let Resident #1 get up and walk out the room with nothing on, I tried to stop Resident #1 from leaving out the room with no pants on but he didn't let me. Before all of this happened I told CNA B multiple times to just leave Resident #1 alone and report he refused, he denied. Record review of skin assessments dated 03/05/26, 03/06/26 (during the day), and 03/06/26 (during the evening) revealed no skin injuries. During an interview on 03/24/26 at 08:10 a.m., the DON stated there was no current administrator. The previous one quit and an interim administrator would be coming the following day. She stated a staff member had reported she witnessed another staff member being aggressive with a resident. She was told the staff member was trying to force him into bed, into clothes and yelling at him. Both staff were suspended due to CNA A not reporting it immediately, and CNA B for the abuse allegation. The staff were all re-in-serviced regarding abuse and timely reporting. During an observation and interview on 03/24/26 at 09:34 a.m., Resident #1 was sitting in his wheelchair in the common area on the Secured Unit. An attempt was made to interview the resident. He was not interview able. During a phone interview on 03/24/26 at 12:45 p.m., CNA B denied the abuse allegations and denied being rough with the resident. He stated he was suspended immediately pending the investigation and then he was terminated. During a phone interview on 03/24/26 at 12:52 p.m., CNA A confirmed she had provided a written statement to the facility regarding the abuse incident. She confirmed CNA B was rough with the resident and manhandled him. She stated she had asked him to leave Resident #1 alone multiple times. She stated CNA B had hit Resident #1 on his arm repeatedly with a closed fist. She stated she was fired due to not reporting promptly. She stated she knew she was supposed to report abuse immediately but did not feel comfortable leaving CNA B alone with the residents on the memory care unit. She reported as soon as she felt comfortable the residents were safe. During a phone interview on 03/25/26 at 11:00 a.m., Resident #1's family member stated she filed charges against CNA B. She stated it would be hard to explain or understand what he thinks of things now.because of how sick he is. I was livid. She stated he never raised a hand to her and never screamed or hollered at her. She stated he didn't deserve that. She stated she was so mad.I want to scrutinize everybody and everything. I don't want anyone to have half the chance of doing that again. She stated it was traumatizing to her. Record review of CNA B's personnel file: Hire date: 02/25/26. Proof of background check and EMR check were provided. Proof of abuse, resident rights, behavioral health, and dementia/cognitive impairment, and abuse report training was completed and signed by CNA B on 02/24/26.Record review of the policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention, Reporting, and Investigation Policy, revised January 2026, indicated .The Nursing Facility (NF) ensures that all residents are free from abuse, neglect, exploitation, misappropriation of resident property, mistreatment .Definitions . Abuse . the willful infliction of injury, unreasonable confinement, intimidation, punishment .resulting in physical harm, pain, mental anguish, or emotional distress .The interim Administrator was notified on 03/25/2026 at 11:35 a.m. that a past non-compliance was identified due to the above failure. The facility implemented the following interventions before the survey entrance on 03/24/2026.- Staff were suspended during the investigation and then terminated.-Assessment of Resident #1.- Completion of in-services regarding abuse/neglect and timely reporting of incidents (03/05 and 03/06/26).- Staff re-educated as to interventions on handling residents with behaviors, abuse/neglect, and resident rights (related to another incident on 03/13/26). To ensure the trainings were completed, 14 staff (DON, ADON, LVN C, LVN D, CNA E, CNA F, CNA G, CNA H, CNA J, CNA K, Dietary L, Dietary M, and CNA N) were interviewed from all shifts on 03/24/26 and 3/25/26. Staff were able to appropriately define abuse, identify the abuse coordinator, and said they would immediately notify the administrator or the DON of any abuse allegations. They were able to state to intervene appropriately and if they were the only two staff on the floor, to call for help using a phone, or to yell out the door for help at the nearby nursing station. The non-compliance was identified as PNC. The IJ began on 03/05/26 and ended on 03/13/26. The facility had corrected the non-compliance before the survey began.

Based on interview, and record review, the facility failed to determine that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 2 of 4 months of controlled drug count records reviewed. The facility failed to ensure the controlled drug (medication) count record was signed acknowledging that the controlled drugs (medications) were counted by LVN A, LVN B, LVN C, MA D, LVN E and LVN F. The facility failed to ensure LVN A, LVN B, LVN C, MA D, LVN E and LVN F signed the controlled drug count records acknowledging the controlled drugs were counted and correct each time they took possession of the medication cart for the months of January and February. This failure could place the facility at risk for drug diversion.Findings included: Record review of the controlled drug count sheets indicated signing below acknowledges that you have counted the controlled drugs on hand and have found that the quantity of each medication counted is in agreement with the quantity stated on controlled Drug Administration Record. missing nursing and MA's signatures for: Hall: Short (MA and Nurse medication cart) 01/7/2026 for shift 10:00 p.m.- 6:00 a.m. by LVN A01/9/2026 for shift 10:00 p.m.- 6:00 a.m. by LVN B01/31/2026 for shift 10:00 p.m.- 6:00 a.m. by LVN C02/20/2026, 02/21/2026, 02/22/2026 for shift 10:00 p.m.- 6:00 a.m. by LVN B02/24/2026 for shift 7:00 a.m.- 7:00 p.m. by MA D Hall: Long (MA cart) 02/05/2026 for shift 7:00 a.m.- 7:00 p.m. by MA D02/15/2026 for shift 7:00 a.m.- 7:00 p.m. by MA D Hall: 100 (Nurses medication cart) 02/02/2026 for shift 2:00 p.m.- 10:00 p.m. by LVN C02/03/2026 for shift 10:00 p.m.- 6:00 a.m. by LVN F02/04/2026 for shift 2:00 p.m.- 10:00 p.m. and 10:00 p.m.- 6:00 a.m. by LVN F02/05/2026 for shift 7:00 a.m.- 7:00 p.m. by LVN B02/21/2026 for shift 2:00 p.m.- 10:00 p.m. and 10:00 p.m.- 6:00 a.m. by LVN F02/25/2026 for shift 2:00 p.m.- 10:00 p.m. and 10:00 p.m.- 6:00 a.m. by LVN F During an interview on 02/26/2026 at 1:55 p.m., LVN C said she had counted the controlled medications before taking the keys for the dates of 01/31/2026 for shift 10:00 p.m.- 6:00 a.m. and 02/02/2026 for shift 2:00 p.m.- 10:00 p.m. She said she could not recall the reason she did not sign the controlled drug (medication) sheet. She said she was responsible for signing the controlled drug sheet at the beginning of her shift and at the end of her shift. She said she should have signed because it shows she counted before taking responsibility for the controlled medications. She said the potential risk was drug diversion and inaccurate drug count documentation. She said she had been trained to sign the controlled drug (medication) sheets when coming and leaving her shift. During an interview on 02/27/2026 at 9:22 a.m., LVN F said the controlled drug (medication) sheet was for nurses and MAs to acknowledge they counted the controlled drugs and had assumed responsibility for the drugs. She said she was responsible for signing the controlled drug sheet at the beginning of her shift and at the end of her shift. She said she had counted the drugs on the dates and shifts of: 02/04/2026 for shift 2:00 p.m.- 10:00 p.m. and 10:00 p.m.- 6:00 a.m., 02/21/2026 for shift 2:00 p.m.- 10:00 p.m. and 10:00 p.m.- 6:00 a.m., 02/25/2026 for shift 2:00 p.m.- 10:00 p.m. and 10:00 p.m.- 6:00 a.m. LVN F said she was human and forgot to sign the controlled drug count record sheet after working doubles. She said her narcotic drug count had always been correct and never had any issues with the count not being accurate. She said the potential risk was drug diversion if the documentation was not completed. During an interview on 02/27/2026 at 9:35 a.m., LVN B said she was responsible for signing the controlled drug sheet at the beginning of her shift and at the end of her shift. She said she could not recall why she did not sign the controlled drug sheet on 01/09/2026 for shift 10:00 p.m.- 6:00 a.m., 02/20/2026, 02/21/2026, 02/22/2026 for shift 10:00 p.m.- 6:00 a.m., and 02/05/2026 for shift 7:00 a.m.- 7:00 p.m. LVN B said she always counted the controlled medication cart before taking responsibility for the controlled medications and had never had any issues with the count being accurate. She said the potential risk was drug diversion if the documentation was not completed. A phone interview was attempted with MA D on 02/27/2026 at 9:43 a.m., there was no answer, voicemail was left. A interview was attempted with LVN E on 02/27/2026 at 10:12 a.m., there was no answer, voicemail was left. During an interview on 02/27/2026 at 10:20 a.m., the DON said she expected the nurses and MA's to sign in and sign off on the controlled drug (medic ation) sheet to ensure the controlled drugs are being counted and accurate to prevent the potential for drug diversion. She said she and the ADON were responsible for reviewing the controlled drug count sheets every Monday and Fridays. She said the drug count sheets had been overlooked because she was still adjusting to her role as DON. She said the controlled drug count sheets should have been signed by the nursing staff that was responsible for medication and reviewed by her and the ADON to ensure it was completed correctly and accurately. During an interview on 02/27/2026 at 10:40 a.m., the Administrator said all nurses and MA's were responsible for signing in and out on the controlled drug count sheet. He said the potential risk was drug diversion and missing medications. During an interview on 02/27/2026 at 5:00 p.m., LVN A said she was responsible for signing the controlled drug sheet at the beginning of her shift and at the end of her shift. She said she could not recall why she did not sign the controlled drug sheet on the dates of 01/7/2026 for shift 10:00 p.m.- 6:00 a.m. She said the potential risk was drug diversion by staff, visitors, or residents. She said she had no issues with the controlled drug count and always had an accurate count of controlled drugs (medications.) An interview attempt was made, but the ADON was off and unavailable to interview. Record review of the facility policy titled: Controlled Substances revision date November 2022 indicated: Policy StatementThe facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976).Policy Interpretation and ImplementationDispensing and Reconciling Controlled Substances Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following:Records of personnel access and usage;Medication administration records;Declining inventory records; andDestruction, waste and return to pharmacy records.Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count.The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.The director of nursing services documents irreconcilable discrepancies in a report to the administrator.If a major discrepancy or a pattern of discrepancies occurs, or if there is apparent criminal activity, the director of nursing notifies the administrator and consultant pharmacist immediately.The administrator, consultant pharmacist, and/or director of nursing services determine whether other action(s) are needed, e.g., notification of police or other enforcement personnel.The medication regimen of residents using medications that have such discrepancies are reviewed to assure the resident has received all medications ordered and the goal of therapy is met (example: a resident receiving a pain medication complains of unrelieved pain).The director of nursing services consults with the provider pharmacy and the administrator to determine whether any further legal action is indicated.

Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse for 1 of 19 residents reviewed for abuse. (Resident #39)The facility failed to ensure Resident #39 was free from physical abuse when on 11/30/25 CNA A slapped Resident #39 in the face. The noncompliance was identified as PNC. The IJ began on 11/30/25 and ended on 11/30/25. The facility corrected the noncompliance before the survey began. This failure could place residents at risk for emotional distress, fear, decreased quality of life, and further abuse.Findings included:Record review of a face sheet dated 12/01/25 indicated Resident #39 was an [AGE] year-old male admitted on [DATE]. His diagnoses included dementia (loss of cognitive functioning) and cerebral infarction (lack of adequate blood supply to brain cells that deprives them of oxygen and vital nutrients which can cause parts of the brain to die off).Record review of the quarterly MDS dated [DATE] indicated Resident #39 had adequate hearing, clear speech, usually understood others, usually made himself understood, had severely impaired cognition with a BIMS of 03 out of 15, and he had no behaviors. Record review of an Incident/Accident Report dated 11/30/25 indicated on 11/30/25 Resident #39 was sitting in bed yelling out and cursing. CNA A was in the room, extended her right hand out, and smacked the left side of Resident #39's face with her open hand. She then stepped back. Resident #39 stated you dirty m@#$%& f@#$%&! CNA A picked up the meal tray and stated, Don't talk to me like that, I am taking care of you! and exited the room. This was witnessed by LVN B. During an observation and interview on 12/01/25 at 08:40 a.m. Resident #39 was in bed. He was clean, neat, and had no lingering odors. There was no visible redness to the left side of his face. He asked surveyor What the f@#$ do you want? Surveyor explained who they were and purpose of visit. Resident #39 said Okay, now get the f@#$ out! During a phone interview on 12/01/25 at 02:42 p.m. LVN B said she was walking the hall when she saw into Resident #39's room. She said he had his arms up and CNA A put her right hand between his arms and slapped Resident #39 on the left side of his face with her open hand. LVN B said CNA A and Resident #39 exchanged words then CNA A picked up his dinner tray and left the room. She said CNA A then went to fill up the ice chest. She said while CNA A was filling up the ice chest, she contacted the DON and informed her of what she witnessed. She said the DON told her to tell CNA A to clock out, go home, and she would contact her. She said CNA A was a good staff member and she had no issues with her. She said she was shocked by CNA A's action towards Resident #39. During an interview on 12/01/25 at 02:58 p.m. the DON indicated she was contacted on 11/30/25 by LVN B regarding incident involving Resident #39 and CNA A. She said LVN B said she was watching CNA A while on the phone with her so CNA A was not entering resident rooms. She said she told LVN B to have CNA A clock out, go home, and she would contact her later. She said she arrived at the facility, assessments were conducted on residents assigned to CNA A. She said safe survey interviews were also conducted. She said ANE in-service was started. She said there had not been any conflicts reported between LVN B and CNA A.During an interview on 12/01/25 at 03:00 p.m. the Administrator said it was his first day at the facility. He said if a staff member was accused of abusing a resident they were to be removed from the situation and ensure the resident was safe. He said the staff member would be sent home and there would be a report made to HHSC. He said an investigation would then be conducted with a written report completed and submitted to HHSC within 5 days. Several attempts were made to contact CNA A on 12/01/25 and 12/02/25 with no success and not able to leave a message. Record review of the Abuse and Neglect policy dated June 2023 indicated the following: Policy Statement: It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation.The administrator was notified of the IJ on 12/02/25 at 03:40 p.m. due to the above failures. The administrator was provided with the IJ template on 12/02/25 at 03:46 p.m. The surveyor confirmed the facility implemented sufficient interventions to remove the Immediate Jeopardy on (11/30/25) by:- Record review of an Employee Change of Status form dated 11/30/25 indicated CNA A was suspended on 11/30/25 pending investigation. - Record review of Skin Assessments indicated Resident #39 and other residents assigned to CNA A were assessed on 11/30/25.- Record review of safe survey questionnaires indicated residents assigned to CNA A were questioned on 11/30/25.- Record review of a facility conducted in-service, Abuse and neglect dated 11/30/25, indicated 21 of 74 facility staff were provided education on the topic.- Interviews with LVN B and LVN H (6a-2p and 2p-10p shifts); CNA D (central supply); CNA K and CNA M (2p-10p shift), CNA L (10p-6a and 6a-2p shifts), and MA J (7a-7p shift) indicated they had received an in-service on ANE on 11/30/25.The noncompliance was identified as PNC. The IJ began on 11/30/25 and ended on 11/30/25. The facility corrected the noncompliance before the survey began.

Based on interview and record review the facility failed to ensure they had an RN for 8 consecutive hours 7 days a week for 8 of 8 months reviewed for RN coverage. * The facility did not have RN coverage every day in April 2025, May 2025, June 2025, August 2025, September 2025, October 2025, and November 2025.* The facility did not have an RN for 8 consecutive hours every day in April 2025, May 2025, June 2025, July 2025, and August 2025.These failures could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as emergency care and disasters. Findings included: During an interview on 12/02/25 at 10:16 a.m. the Administrator said on the Exel form of the RN hours the Raw Hours were potential hours to work and the Work Hours were the actual hours worked. He said he clarified if there were no hours under the Work Hours then the nurse did not work. During an interview on 12/03/25 at 01:56 p.m. HR said there were only 2 RNs employed at the facility-the DON and RN R. Record review of the RN time sheets for April 2025 indicated:* there was no RN coverage for 04/04 (FR), 04/11 (FR), 04/18 (FR), and 04/25 (FR); * RN R worked:-04/05 (SA) from 09:25 p.m. to 12 a.m.-2.5 hours-04/19 (SA) from 01:14 p.m. to 06:32 p.m.-4.75 hours-04/26 (SA) from 09:31 p.m. to 12 a.m.-2.5 hours The DON and no other RN worked on these days. Record review of the RN time sheets for May 2025 indicated:* there was no RN coverage for 05/02 (FR), 05/09 (FR), 05/10 (SA), 05/16 (FR), 05/23 (FR)* RN R worked:-05/03 (SA) from 08:42 a.m. to 02:32 p.m.-5.25 hours-05/03 (SA) from 09:31 p.m. to 12 a.m.-2.5 hours (not consecutive)-05/24 (SA) from 08:08 a.m. to 03:14 p.m.-6.5 hours-05/30 (FR) from 01:03 p.m. to 03:27 p.m.-2.5 hours-05/31 (SA) from 07:43 a.m. to 02:49 p.m.-6.5 hours* The DON worked:-05/30 (FR) for 3 hoursThe DON and no other RN worked on these days. Record review of the RN time sheets for June 2025 indicated:* there was no RN coverage for 06/14 (SA), 06/21 (SA), 06/27 (FR), and 06/28 (SA)* RN R worked:-06/06 (FR) from 07:26 a.m. to 12:23 p.m.-4.75hours-06/13 (FR) from 08:00 a.m. to 12:24 p.m.-4.5 hours -06/20 (FR) from 07:12 a.m. to 12:29 p.m.-4.75 hoursThe DON and no other RN worked on these days. Record review of the RN time sheets for July 2025 indicated:* there was no RN coverage for 07/03 (TH), 07/04 (FR), 07/05 (SA), 07/11 (FR), 07/19 (SA), and 07/25 (FR)* RN R worked:-07/12 (SA) from 08:15 p.m. to 02:41 p.m.-5.75 hours-07/18 (FR) from 09:43 p.m. to 12 a.m.-2.25 hours-07/19 (SA) from 12:01 a.m. to 06:01 a.m.-6 hoursThe DON and no other RN worked on these days. Record review of the RN time sheets for August 2025 indicated:* there was no RN coverage for 08/01 (FR), 08/08 (FR), 08/15 (FR), 08/17 (SA), 08/23 (SA), and 08/24 (SU)* RN R worked on -08/16 from 11:29 p.m. to 12 a.m.-0.5 hours-08/17 from 12:01 a.m. to 06:55 a.m.-7 hoursThe DON and no other RN worked on these days. Record review of the RN time sheets for September 2025 indicated there was no RN coverage for 09/01 (MO), 09/06 (SA), 09/07 (SU), 09/13 (SA), 09/14 (SU), 09/20 (SA), 09/21 (SU), 09/27 (SA), and 09/28 (SU).The DON, RN R, and no other RN worked on these days. Record review of the RN time sheets for October 2025 indicated there was no RN coverage for 10/04 (SA), 10/05 (SU), 10/11 (SA), 10/12 (SU), 10/18 (SA), and 10/19 (SU).The DON, RN R, and no other RN worked on these days. Record review of the RN time sheets for November 2025 indicated there was no RN coverage for 11/01 (SA), 11/02 (SU), 11/08 (SA), 11/09 (SU), 11/16 (SU), 11/22 (SA), 11/23 (SU) and 11/27 (TH).The DON, RN R, and no other RN worked on these days. During an interview on 12/03/25 at 02:05 p.m. the DON said there was only her and RN R as the RNs in the facility. She said she tried to cover as much of the RN hours as possible but just could not do it all. During an interview on 12/03/25 at 02:52 p.m. the Administrator said he noticed when he was provided the information on the RN coverage he saw there was an issue with the RN coverage. He said there should be an RN on duty 8 hours a day every day. Record review of a Departmental Supervision, Nursing policy revised August 2022 indicated: Policy Statement: The nursing services department shall be under the direct supervision of a registered or licensed practical/vocational nurse at all times.Policy Interpretation and Implementation:. 2. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident.

Based on interview and record review the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. The facility failed to submit direct care staffing information on the schedule specified by CMS (Centers for Medicare and Medicaid Services), but no less frequently than quarterly for 1 of 4 quarters reviewed for payroll data information. (Quarter 3 2025) *The facility failed to submit staffing information to CMS for the 3rd quarter of the fiscal year 2025. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings included:Record Review of the facility's Civil Rights form (3761) dated 12/03/25 indicated the following:2 RNs 9 LVNs 20 Direct Care Staff9 Dietary8 Housekeeping & Laundry 6 All OthersRecord review of the CMS PBJ Staffing Data Report (payroll-based staffing), CASPER Report (Certification and Survey Provider Enhanced Report) 1705D FY Quarter 3 2025 (April 1- June 30), dated 11/25/2025, indicated the following entry: Failed to Submit Data for the Quarter Triggered .Triggered=No Data Submitted for the Quarter. During an interview on 12/02/25 at 09:22 a.m., HR said the corporate HR department was responsible for submission of the staffing data to CMS every quarter (every three months). A policy regarding the PBJ reporting was requested. During an interview on 12/03/25 at 01:50 p.m. the Administrator indicated he understood corporate handled the PBJ reports. The facility did not have a PBJ reporting policy.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 2 units (secure unit) and room [ROOM NUMBER] and room [ROOM NUMBER] reviewed for homelike environment. 1.The facility failed to provide home-like furniture in TV room and dining room area just with a table. 2.The facility failed to ensure the walls of room [ROOM NUMBER] and room [ROOM NUMBER] did not have scratches and areas of missing paint. 3.The facility failed to provide a clean and sanitary bathroom for room [ROOM NUMBER]. These failures placed the staff and visitors at risk of living and working in conditions of institution which can lead to decline of mental, social skills and increase of behaviors. Findings included: During an observation on 12/03/25 at 11:30 a.m. revealed a plain table with no placements or tablecloths. The table had no decorations. The dining room area / TV room had bare walls and was not homelike. The TV area had no furniture like chairs, end tables or couches. During observations on 12/03/25 at 11:45 a.m. revealed Resident room [ROOM NUMBER] and Resident room [ROOM NUMBER] had areas of missing paint by the beds and scratches on the sheet rock. During observations on 12/03/25 at 11:50 a.m., Resident room [ROOM NUMBER]'s shower had a missing grate over the shower drain leaving a 3-inch hole and both corners of the shower areas had spider's webs. The grout in the shower was discolored and was 2 inches thick and 3-4 inches wide along the base of the walls of the shower. During an interview on 12/03/25 at 2:00 p.m., CNA N said the secure unit needed some homelike furniture in the TV/ dining room. CNA N and CNA P both said the resident rooms need to be painted. CNA N said the unit needed to be homelike for the resident's mental happiness. They said they had not reported the secure unit for not being homelike because this was the way it had been. During an interview on 12/03/25 at 2:10 p.m., the maintenance supervisor said the walls needed repairs and paint. He said the grout would have to be removed and he would remove spider web. He said he was responsible for repairs and removing spiders. He said the residents needed homelike environment for comfort. During an interview on 12/03/25 at 2:15 p.m., the Administrator said the secure unit needed to be updated with paint and furniture. He said the residents deserved homelike environment with decorations and personal items. He said the facility had started with some painting and remodeling in the front of the building. Record review of the facility's Homelike Environment policy dated May 2017 indicated Residents are provided with a safe , clean, comfortable and homelike environment . The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a. Clean, sanitary and orderly environment.Inviting colors and decor.

Based on interview and record review the facility failed to implement the written abuse policy that prohibit mistreatment, neglect, and abuse of residents, for 7 of 7 staff reviewed for abuse. (LVN A, LVN F, Former SW, CNA B, CNA G, CNA M, and CNA Q)The facility did not screen potential employees LVN A, LVN F, Former SW, CNA B, CNA G, CNA M, and CNA Q to include attempting to obtain information from previous employers and/or current employers.This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.Findings included:Record review of the Abuse and Neglect policy dated June 2023 indicated the following: Policy Statement: It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation.I. Screening (483.13 (c)(l)(ii)(A) & (B): Have procedures to: Screen potential employees for a history of abuse, neglect, exploitation, misappropriation of property, or mistreating residents This includes attempting to obtain information from previous employers and/or current employers and checking with the appropriate licensing boards and registries.Record review of employee files indicated the following had no documentation of information from previous employers and/or current employers:* LVN A, hire date 06/26/25;* LVN F, hire date 09/18/25;* Former SW, hire date, 07/10/25;* CNA B, hire date 06/11/25;* CNA G, hire date 11/12/25;* CNA M, hire date 09/11/25; and * CNA Q, hire date 10/16/25.During an interview on 12/02/25 at 10:25 a.m. HR said there was no documentation in the employee files where the previous/current employers were contacted. During an interview on 12/03/25 at 11:20 a.m. the Administrator said if there was no documentation in the employee files then there was no way to show the checks were done.

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure food items in the dry pantry were labeled, dated, and sealed.This failure could place residents that eat out of the kitchen at risk for foodborne illnesses.Findings include:An observation of dry storage on 12/01/2025 at 8:10 AM indicated the following:*2 large plastic gallon zipper top bags each with an 5-pound, opened and used original container bag labeled cornbread and muffin mix with no use by date or open date,*1, 11-ounce box of vanilla wafers with bag ripped open in the original yellow Nilla wafer box. The tabs were opened, and the bag was not sealed, exposing the wafers to the elements, with no use by date or open date,*1, opened and used 12-ounce bag of Best Choice ribbon pasta not sealed and with no use by date or open date,During an interview on 12/01/2025 at 8:20 AM, the DM said she did not know when or who opened the muffin mix, wafers, or pasta and would discard them. The DM said all products should have a received date or used by date and should be sealed. She said packages of food items should be sealed so as not to expose food to the elements. The DM said it was the responsibility of all the dietary staff to ensure products were labeled and stored correctly. The DM said she was the person responsible for monitoring kitchen staff and ensuring products are labeled, sealed, and dated. She said she usually checked every Monday, but had not had a chance that day because of the survey. The DM said all kitchen staff completed the required food preparation and food storage training. The DM said the potential harm to residents would be food poising, rodents getting into stored food if not properly sealed, sickness, and bacteria on food. The DM said the failure occurred due to staff not paying attention. During an interview on 12/03/2025 at 3:20 PM, the Administrator said his expectation was for kitchen staff to follow policies on food storage, preparation, and that everything was dated. He said the DM was responsible for monitoring that kitchen staff were following the facility's policy. The Administrator said not storing and preparing food appropriately could cause residents to be given food beyond the expiration date and not the correct time frame. The Administrator said it could also affect the freshness and quality of residents' food. Record review of the facility's policy revised dated November 2022 titled, Food Receiving and Storage: .Dry Food Storage reflected .3. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. 4. Dry foods that are stored in bins will be removed from original packing, labeled and dated (use by date). Record review of the Food and Drug Administration Food Code, dated 2022, reflected, . 3-201.11 Safe, Unadulterated, and Honestly Presented. Compliance with Food Law. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse and neglect for 10 of 25 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #9, Resident #11, Resident #14, and Resident #216) reviewed for abuse. 1. The facility failed to ensure Resident #6 was free from sexual abuse when Resident #25 came into Resident #6's room and rubbed her right leg under the covers on 08/21/2025.2. The facility failed to ensure Resident #5 was free from physical and verbal abuse by CNA F when CNA F called Resident #5 retarded, pushed and held him down on the bed during incontinent care, pulled him off the low bed, landing on the floor and held him down by his shoulder trying to put his shirt on and pinned him against the wall and stomped on his feet on 7/01/2025. 3. The facility failed to ensure Resident #5 was free from physical and verbal abuse by CNA M when CNA M told Resident #5 to sit your ass down multiple times and then forcefully push Resident #5 into a chair sometime in June 2025. 4. The facility failed to ensure Resident #5 was free from physical abuse when Resident #12 had a physical altercation with Resident #5 when Resident #5 wandered into his room causing Resident #5 to receive a scratch on his chest and a scratch on his back on 07/03/25.5. The facility failed to ensure Resident #5 was free from physical abuse when Resident #13 hit Resident #5 on his chest on 05/26/2025 with no injury.6. The facility failed to ensure Resident #2 & #3 was free from physical abuse when Resident #1 spit on and scratched Resident #2 and scratched Resident #3 on 3/19/2025. 7. The facility failed to ensure Resident #2 was free from physical abuse when Resident #1 pinched Resident #2 on 9/04/2025.8. The facility failed to ensure Resident #3 was free from physical abuse when Resident #1 grabbed her hand and would not let go resulting in Resident #3 hitting Resident #1 on 7/24/2025.9. The facility failed to ensure Resident #1 & #3 was free from physical abuse when Resident #1 and Resident #3 were hitting each other on 8/13/2025.10. The facility failed to ensure Resident #9 was free from physical abuse when Resident #1 ran over Resident #9's foot with her wheelchair and he responded by punching Resident #1 in the face on 7/11/2025.11. The facility failed to ensure Resident #4 was free from physical abuse when Resident #1 hit Resident #4 on her arm on 9/5/2025. 12. The facility failed to ensure Resident #2 was free from physical abuse when Resident #3 scratched Resident #2 who was trying to prevent her from getting coffee on 5/18/2025. 13. The facility failed to ensure Resident #2 was free from physical abuse when Resident #4 hit Resident #2 when Resident #2 took Resident #4's bingo tokens on 6/11/2025. 14. The facility failed to ensure Resident #2 was free from physical abuse when Resident #15 hit Resident #2 in the face and knocked off her glasses on 7/4/2025.15. The facility failed to ensure Resident #14 was free from physical abuse when Resident #4 hit Resident #14 in the chest and pushed her walker on 6/19/2025. 16. The facility failed to ensure Resident #11 was free from physical abuse when Resident #10 hit Resident #11 on the back of the head on 06/19/2025. 17. The facility failed to ensure Resident #216 was free from physical abuse when Resident #215 slapped Resident #216 on 5/12/2025. An Immediate Jeopardy (IJ) was identified on 09/24/2025 at 9:45 a.m. The IJ template was provided to the facility on [DATE] at 11:05 a.m. While the IJ was removed on 09/25/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk of emotional distress, fear, decreased quality of life and further abuse. Findings included: Resident #6 Record review of Resident #6's face sheet, dated 09/24/2025, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #6 had diagnoses which included cerebral infarction (occurs when blood flow to part of the brain is blacked leading to tissue death), schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges) conversion disorder with seizures or convulsions (mental health condition in which individuals experience neurological symptoms without any detectable neurological or medical cause),acquired absence of left leg below the knee (loss of leg below the knee) and hemiplegia (total paralysis or severe loss of muscle function on one side of the body) following cerebral infarction. Record review of Resident #6's quarterly MDS Assessment, dated 06/10/2025, indicated she had a BIMS score of 14 and diagnoses of hemiplegia, cerebral infarct, schizophrenia and seizure disorder. The assessment indicated Resident #6 was dependent for transfer and needed supervision for locomotion in manual wheelchair for 50 feet. Record review of Progress Notes dated 08/22/2025 indicated Resident #6 received 72-hour trauma monitoring by the SW related being touched inappropriately and without consent by Resident #25, no emotional distress indicated. Record review of Progress Notes dated 08/25/2025 indicated Resident #6 received 72-hour trauma monitoring by the SW related being touched inappropriately and without consent by Resident #25, no emotional distress indicated. Record review of Progress Notes dated 08/26/2025 indicated Resident #6 received 72-hour trauma monitoring by the SW related to being touched inappropriately and without consent by Resident #25, no emotional distress indicated. Record review of Resident #6's quarterly MDS Assessment, dated 09/10/2025, indicated she had a BIMS score of 12 and diagnoses of hemiplegia, cerebral infarct, schizophrenia and seizure disorder. The assessment indicated Resident #6 was dependent for assistance of 1 to 2 persons for transfer and dependent for locomotion in manual wheelchair for 50 feet. Record review of Resident #6's care plan with a target date of 11/18/2025 indicated Resident #6 had a diagnosis of schizophrenia and is at risk of increased behaviors. Interventions included intervene and monitor resident for increased agitation, anger, verbal and physical aggression, and document episodes of behavior. Record review of Resident #6 police report dated 08/21/202025 indicated a crime incident of assault, the victim was Resident #6, and she notified the officer that Resident #25 entered her room put his hand under her leg and rubbed his hand on her leg. She said Resident #25 stated, “I'm sorry it just feels so good to feel skin so soft.” Resident #6 indicated she felt it was a sexual nature, and she wished to file a report. The report indicated a non-consent form was signed. Resident #25 Record review of Resident #25's face sheet, dated 09/24/2025, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #6 had diagnoses which included hemiplegia following cerebral infarction, morbid obesity (having too much body fat which increases the risk of health problems), cerebral infarction, post- traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) and convulsions. Record review of Resident #25's quarterly MDS Assessment, dated 09/19/2025, indicated he was cognitively independent and had no long-term or short-term memory problem. The assessment indicated Resident #25 required dependence of 1 or 2 persons to transfer from bed to chair and independent of locomotion in a motorized scooter. Record review of Resident #25's Change in Condition Evaluation on 08/21/2025 indicated he had behavior symptoms of sexual behaviors with Resident #25 redirected to his room and sent to a behavioral hospital for monitoring. Record review of Resident #25's care plan with a revision date of 08/22/2025 indicated Resident #25 had inappropriate sexual behaviors and was at risk of further episodes and injury. The Care plan indicated Resident #25 had a history of allowing an intellectually challenged resident perform oral sex on him in the dining room and on 08/21/25 was witnessed rubbing on the leg of another resident that was unwanted. Interventions included to redirect during episodes of inappropriate sexual behavior and document in the clinical record, firmly approach the resident that behaviors are not acceptable. The care plan indicated on 08/21/25 Resident #25 was sent out for a psychiatric evaluation, was on 1 on 1 monitoring and psychiatric referral made in house by the nurse practitioner and discharge planning. During an observation and interview on 09/22/2025 at 10:00 a.m., Resident #25 named in the allegation was lying in bed, he denied sexual abuse of Resident #6. He said he brought his friend Resident #6 a cup of coffee and she was on the verge of tears. Resident #25 said Resident #6 told him no one liked her, and he said everyone here likes you and rubbed her lower leg on top of the covers. Resident #25 said he did not sexually touch anyone inappropriately. He said he was comforting his friend. Resident #25 said a nurse came into the room, did not ask any questions and made a mountain out of a mole hill. Resident #25 said he was sent to the hospital to be evaluated and had not been to Resident #6's room since the incident. During an observation and interview on 09/22/2025 at 10:20 a.m., Resident #6 named in the allegation, was up in her scooter with a left below the knee amputee, she said she was treated well, received needed care, call lights answered timely, and she denied abuse/ neglect. Resident #6 said she felt safe in the facility and was comfortable reporting concerns to the nurse. She said Resident #25 was not allowed in her room. Resident #6 said the day of the incident (08/21/2025) Resident #25 brought her coffee and that it was fine, but she said he started rubbing her right lower leg under the covers. She said she told him, ”I don't like that, she said she did not say stop.” Resident #6 said a nurse came into the room and Resident #25 stopped and left the room. She said I was very upset when it happened but now felt safe in the facility. During an interview on 09/23/2025 at 4:30 a.m., Resident #6 said Resident #25 said her skin was so soft he could not help himself when he rubbed her leg the day of the incident (08/21/2025). During a phone interview on 9/23/2025 at 4:00 p.m., Hospice RN said on 08/21/2025 she was in Resident #6's room visiting her roommate and heard Resident #25 say “I want to feel your soft skin”, she said Resident #25 had his hand under Resident #6's covers. Hospice RN said Resident #25 saw her, stopped touching Resident #6 and left the room. She immediately reported the incident to LVN X and then wrote her statement. She said she did not say anything to Resident #25. The Hospice RN said she heard LVN X ask Resident #6 if she asked Resident #25 to do that and she said no and cried. During an interview on 09/23/2025 at 12:00 p.m., LVN X said she did not witness the incident on 08/21/2025 with Resident #6 and Resident #25. She said the Hospice RN notified her she witnessed Resident #25 rubbing Resident #6's leg under the covers of her bed. LVN X said Resident #25 said Resident #6 asked me to come into her room. LVN X said Resident #25 said Resident #6 said no one loved her and he touched her leg. LVN X said Resident #25 normally gets up early, goes outside for the morning then back to bed but not normally into other resident rooms. She said there was no reason for him to visit down Resident #6's hall. LVN X said Resident #6 said she did not give Resident #25 consent to touch her. She immediately notified the DON, ADON and Administrator. LVN X placed Resident #25 on 1 on 1 monitoring after the incident. She said that meant constant monitoring, eyes and ears on Resident #25, a CNA sat outside his room and stared at him in his room alone. She completed an assessment on both residents with no injury noted. LVN X said Resident #25 was sent out to the hospital later that night. She said Resident #25 required 2 CNAs to get Resident #25 out of bed and transferred to his scooter. LVN X said Resident #25 was not allowed to go to Resident #6's room. She was in-serviced prior to the incident on abuse/ neglect and sexual abuse prevention. She said after the incident she was in-serviced on abuse/ neglect and sexual abuse prevention. Resident #12 Record review of Resident #12's face sheet, dated 09/24/2025, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #12 had diagnoses which included dementia, seizures, bipolar disorder (chronic mental health condition characterized by extreme mood swings between periods of mania {elevated mood} and depression) and abnormalities of gait and mobility (deviations from the normal pattern of walking and movement). Record review of Resident #12's admission MDS Assessment, dated 06/05/2025, indicated he had long and short-term memory loss and was severely impaired of cognition, rarely/ never understood and rarely/never understood understands. The assessment indicated Resident #12 had inattention and disorganized thinking behaviors continuously present. Record review of Resident #12's quarterly MDS Assessment, dated 09/01/2025, indicated he had long and short-term memory loss and was severely impaired of cognition, rarely/ never understood and sometimes understands. He had wandering behaviors that occurred 1 to 3 days within the 7 days look back period. Resident #5 had physical behaviors, verbal behaviors and other behavioral symptoms 1 to 3 days within the 7 days look back period. Record review of Resident #12's care plan dated 07/08/2025 indicated Resident #12 scratched another resident when the other resident wandered into his room. Interventions included intervene as necessary to protect the rights and safety of others, approach/ Speak in a calm manner, divert attention and remove from situation and take to alternate location as needed. Record review of an incident report for physical aggression, dated 07/04/2025, indicated an incident was reported that included Resident #5 and Resident #12 with the allegation of abuse. Record review of the facility's PIR, dated 07/11/2025, incident category as other and other specified as a resident-to-resident incident signed by the Administrator on 07/11/2025. The PIR indicated the incident occurred on 07/03/2025 at 7:05 a.m., on the secure unit. The PIR indicated Resident #5 went into Resident #12's room and rummaged, Resident #12 became physically aggressive in an attempt to remove Resident #5 from his room and Resident #5 received scratches to back and chest. Residents were separated immediately, LVN S performed a head-to-toe assessment on both residents, Resident #12 received no injury. Resident #5 was placed on 1:1 supervision and scratches treated. The physician was contacted and gave orders for Resident #5 to have an emergency room psych evaluation with medication changes. Reeducated staff on abuse and neglect, with no concerns, Social Worker conducted resident safe survey interviews with no concerns and IDT team met and discussed incident and updated care plans. Investigation findings: Confirmed that residents did have a person-to-person interaction with no major injury, Resident #5 received a scratch to his back and chest. Record review of Resident #12's physician orders dated 09/24/2025 indicated he was prescribed sertraline (antidepressant medication) 100 mg daily for major depressive disorder (a mental health condition characterized by persistent feelings of deadness, hopelessness and loss of interest or pleasure in activities) with a start date of 07/09/2025 and Aripiprazole (antipsychotic medication) 15 mg daily for bipolar disorder. During an observation and interview on 09/24/2025 at 1:44 p.m., Resident #12 was sitting in recliner, he denied abuse/ neglect and said he felt safe in the facility. Resident #12 denied anyone came into his room and messed with his stuff and denied allegations of scratching or hitting Resident #5. During an Interview on 09/24/2025 at 1:55 p.m. LVN S said Resident #5 was found on the floor in Resident #12's doorway with Resident #12 yelling to get out and trying to shut his door. She said she separated residents and assessed both residents. LVN S said Resident #5 had a scratch on his back and chest and was placed on 1 on 1 monitoring. She said Resident #12 had no injuries. She said she Notified psychiatric services the ADON, DON, Administrators, responsible parties and physicians. Resident #13 Record review of Resident #13's face sheet, dated 09/24/2025, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Resident #13 had diagnoses which included cerebral infarction (a condition where blood flow to the brain was interrupted leading to brain cell damage), abnormalities of gait and mobility, compression of brain (increased pressure within the skull that compresses the brain tissue), muscle weakness, lack of coordination and cognitive communication deficit. Record review of Resident #13's admission MDS Assessment, dated 03/19/2025, indicated she had a BIMS score of 9 and was moderately impaired of cognition. The assessment indicated Resident #13 had inattention and disorganized thinking behaviors present that fluctuated (comes and goes and changes in severity). Resident #13's assessment indicated delusions (misconceptions or beliefs that are firmly held, contrary to reality) and verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others occurred 1 to 3 days of the 7day look back period. Record review of Resident #13's care plan dated 05/27/2025 indicated Resident #13 was at risk of manic episodes and increased behaviors with interventions of monitor for increased agitation and removed from increased stimuli. Record review of an incident report for physical aggression, dated 05/26/2025, indicated an incident was reported that included Resident #5 and Resident #13 with the allegation of abuse. Resident #13 was sent to the emergency room for a psychological evaluation and neither resident had injuries. Record review of the facility's Provider Investigation Report, dated 06/02/2025, incident category as other and other specified as a resident-to-resident incident signed by the Administrator on 06/02/2025. The PIR indicated the incident occurred on 05/26/2025 at 4:30 p.m. on the secure unit. The PIR indicated Resident #13 hit Resident #5 with a mop handle. LVN S witnessed the incident and separated the two residents and placed Resident #13 on 1 on 1 until she was transferred to the emergency room and did not return to the facility. Investigation Findings: Confirmed that residents did have a person-to-person interaction with no injury, all metal objects and possible safety hazards removed from the unit. Staff in-serviced on abuse/ neglect and safe surveys indicated no patterns of abuse/ neglect on the secured unit. Record review of Resident #13's physician orders dated 09/24/2025 indicated she was prescribed divalproex 125 mg daily for mood disorder (a mental and behavioral disorder) with a start date of 05/09/2025. During an observation and interview on 09/24/2025 at 1:40 p.m., Resident #5 was sitting in a chair, he denied anyone hit him or hurt him and he denied hitting anyone. Resident #5 was confused and unable to answer more than a few questions. During an interview on 09/24/2025 at 1:55 p.m., LVN S said she witnessed the Resident #13 and Resident #5 incident on 05/26/2025. LVN S said Resident #13 barely bumped Resident #5 in the chest with a broom. She said there was no redness or injury on either resident nor were they upset. She separated the residents, put Resident #13 on 1 on 1 monitoring and sent her to the emergency room. LVN S said she notified the responsible parties for both residents, physicians, DON and Administrator. Resident #5 Record review of Resident #5's face sheet, dated 09/23/2025, indicated a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 had diagnoses which included diffuse traumatic brain injury (widespread damage across multiple areas of the brain), hypertension (a condition in which the force of the blood against the artery walls is too high), encephalopathy (group of conditions that cause brain dysfunction, which can manifest as confusion, memory loss, personality changes), dementia (loss of cognitive functioning), lack of coordination, cognitive communication deficit, and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #5's quarterly MDS Assessment, dated 5/04/2025, indicated he rarely/never made himself understood and sometimes understood others. He was not assessed for the brief interview for mental status because he is rarely/never understood. He had no behaviors identified within the 7-day look back period. Record review of Resident #5's quarterly MDS Assessment, dated 08/04/2025, indicated he had long and short-term memory loss and was severely impaired of cognition, rarely/ never understood and sometimes understands. He had wandering behaviors that occurred 1 to 3 days within the 7 days look back period. Resident #5 had physical behaviors, verbal behaviors and other behavioral symptoms 1 to 3 days within the 7 days look back period. Record review of Resident #5's care plan revision dated 7/03/2025 indicated Resident #5 had an incident of confabulation and had a potential for further episodes of confabulation and confabulation triggered behaviors. Interventions included allow residents to verbalize feelings during episodes of confabulation - gently reorient and maintain safety, orient/re-orient resident daily and PRN, encourage to attend activities of choice, and report to MD/RP as needed and document episodes of confabulation in the clinical record. Record review of Resident #5's care plan dated 08/22/2025 indicated Resident #5 had inappropriate behaviors. Interventions included monitor and chart behaviors every shift and report progress to the physician, observe for early warning signs of behavior, approach in a calm manner, call Resident #5 by name and remove from unwanted stimuli. Record review of the facility's Provider Investigation Report (PIR) dated 7/01/2025, incident category as abuse signed by the Administrator on 7/11/2025. PIR indicated the incident occurred 7/01/2025 at 7:00 p.m. on the secure unit. PIR indicated CNA D witnessed CNA F be verbally and physical aggressive with Resident #5. On 7/01/2025, CNA D witnessed CNA F hit Resident #5's head against the wall and pinch him. CNA F was heard calling Resident #5 retarded” and making statements “if these cameras were not here, I would do what I really wanted to do.” LVN X provided head to toe assessment to Resident #5 with no injuries noted. Provider response after the incident included, employee suspended immediately, head to toe assessments on all residents in the secure unit, safe surveys conducted, employee statements collected, abuse and neglect in-services initiated, care plan updated, psych NP notified, MD notified, no family to notify, and local police contacted. Resident abuse confirmed. Employee terminated. During an observation on 9/23/2025 at 11:00 a.m., Resident #5 was well groomed, and appropriately dressed. Resident #5 was ambulating independently in the secure unit hallways and in the outdoor secure area. Resident #5 with no signs of abuse or fear of staff identified. During an interview on 9/23/2025 at 12:53 p.m., CNA D said on 7/01/2025 CNA F had asked her to assist with incontinent care on Resident #5, she said during assisting with care she witnessed CNA F push and held Resident #5 down on the bed during incontinent care. CNA D said CNA F held Resident #5's arm down with her knee when Resident #5 slapped her on the arm. CNA D said CNA F told Resident #5 she would sit on him if he hit her again and then she pinched him. CNA D said CNA F roughly pull Resident #5 off the low bed, landing on the floor and holding him down by his shoulder trying to put his shirt on. CNA D said CNA F pin Resident #5 against the wall and stomped on his feet in the attempt to get him dressed. CNA D said she was a new employee at the time of the incident and was shocked at what she witnessed, she said she reported the incident to the administrator. CNA D said she should have stopped the abuse at the time of the incident but was so shocked by the event she was reluctant to say anything to the seasoned staff member. An attempted telephone interview on 09/23/2025 at 1:15 p.m. with CNA F, the alleged perpetrator was unsuccessful. Record review of CNA F employee statement dated 07/01/2025 indicated “changing patient on bed, laid him down to change him, he was kicking, told him to stop put diaper on him had to use a little force because he was scratch and kicking me.” Record review of CNA F employee termination form dated 07/07/2025 indicated CNA F was terminated for violation of company policy and a substantiated abuse allegation. During an interview on 9/23/2025 at 1:30 p.m., LVN X said she recalled she assessed Resident #5 after the incident and did not identify any injuries but does not recall how she became aware of the incident. She said if she was notified of an abuse allegation, she would make sure the resident was safe and then immediately report to the Administrator/Abuse Coordinator. She said if she witnessed a resident being abused that she would intervene and remove the abuser and keep the resident safe, notify the AC and/or send the staff member home and if resident to resident keep separated for safety. Record review of the facility's PIR dated 7/01/2025, incident category as abuse signed by the Administrator on 7/11/2025. PIR indicated the incident occurred 7/01/2025 at 7:00 p.m. on the secure unit. PIR indicated during staff interviews ST R said she witnessed CNA M be verbally and physical aggressive with Resident #5 approximately 1.5 weeks ago. CNA M was heard telling Resident #5 to “sit you ass down” and witnessed forcefully pushing him into the chair and pushing his chair forcefully under the table. LVN X provided head to toe assessment to Resident #5 with no injuries noted. Provider response after the incident included, employee suspended immediately, head to toe assessments on all residents in the secure unit, safe surveys conducted, employee statements collected, abuse and neglect in-services initiated, care plan updated, psych NP notified, MD notified, no family to notify, and local police contacted. Resident abuse confirmed. Employee terminated. During an interview on 09/24/2025 at 2:00 p.m., ST R said she had witnessed CNA M physically and verbally abuse Resident #5 sometime in late June 2025 when she heard CNA M tell Resident #5 to sit you ass down multiple times and then forcefully push Resident #5 into a chair and push him up to the table. ST R said she reported this incident late, when she was being interviewed regarding another incident with Resident #5. She said at the time it happened she felt uneasy about the incident and would not want her family treated that way. She said she reported the incident to clear her consciousness and knew it should have been reported when she first witnessed the incident. She said she was suspended and received disciplinary actions regarding not reporting the abuse allegation immediately and re-educated prior to returning to work. She said moving forward that any abuse allegations witnessed or reported to her she would report it immediately to the administrator. An attempted telephone interview on 09/23/2025 at 1:17 p.m. with CNA M, the alleged perpetrator was unsuccessful. Record review of CNA M employee statement dated 07/03/2025 indicated “Resident #5 was ambulated to chair, sat him down and scooted his chair up to the table, so he would be able to eat his lunch tray. If this happened a week ago why it just now being reported on 07/03/2025, the abuse coordinator number is all over the building.” Record review of CNA M employee termination form dated 07/07/2025 indicated CNA M was terminated for violation of company policy and a substantiated abuse allegation. During an interview on 9/23/2025 at 1:30 p.m., LVN X said she recalled assessing Resident #5 after the incident and did not identify any injuries but does not recall how she became aware of the incident. She said if she was notified of an abuse allegation, she would make sure the resident was safe and then immediately report to the Administrator/Abuse Coordinator. She said if she witnessed a resident being abused that she would intervene and remove the abuser and keep the resident safe, notify the AC and/or send the staff member home and if resident to resident keep separated for safety. Resident #1 Record review of Resident #1's face sheet, dated 09/23/2025, indicated a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included cerebral palsy (congenital disorder of movement, muscle tone, or posture due to abnormal brain development), aphasia (disorder that affects language after a stroke), dysphagia (difficulty swallowing after a stroke), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #1's quarterly MDS Assessment, dated 8/08/2025, indicated she was sometimes able to make herself understood and usually understood others. She had severe cognitive impairment, identified with a BIMS score of 3. She had an active diagnosis of psychotic disorder and depression in the last 7 days. She had no behaviors identified within the 7 days look back period. Record review of Resident #1's care plan revision dated 11/11/2024 indicated Resident #1 had physical aggression. Interventions included to Intervene before agitation escalates; guide away from source of distress; Engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later, administer medications as order and document side effects and effectiveness, assess and address for contributing sensory deficits and monitor/document/report as needed any s/s of resident posing danger to self and others, and consult psychiatric/psychogeriatric as indicated. Record review of Resident #1's care plan dated 7/12/2025 indicated Resident #1 had impulse control. Interventions included assessing coping skills and support system, analyzing key times, places, circumstances, triggers, and what de-escalates, and assessing and anticipating resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Record review of Resident #1's care plan revision dated 8/13/2025 indicated Resident #1 had physical aggression. Interventions included to place on 1:1 monitoring for 2 hours and separate from another resident, intervene before agitation escalates; guide away from source of distress; Engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later, administer medications as order and document side effects and effectiveness, assess and address for contributing sensory deficits and monitor/document/report as needed any s/s of resident posing danger to self and others, and consult psychiatric/psychog

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 7 of 25 residents (Resident's #1,2,3,4,5, 6, 25) reviewed for care plans. 1. The facility failed to develop and implement interventions in Resident #25's the care plan revised 08/22/2025 to prevent Resident #25's inappropriate and unwanted touching of Resident #6 on 08/21/25. 2. The facility failed to ensure Resident #1's care plan was updated to indicate Resident #1 had an incident of resident-to-resident aggression on 03/19/2025, 07/24/2025 and 09/05/2025. 3. The facility failed to ensure Resident #2's care plan was updated to indicate Resident #2 had received aggression during a resident-to-resident incident on 03/19/2025. 4. The facility failed to ensure Resident #3's care plan was updated to indicate Resident #3 had received aggression during a resident-to-resident incident on 03/19/2025 and 07/24/2025. 5. The facility failed to ensure Resident #4's care plan was updated to indicate Resident #4 had received aggression during a resident-to-resident incident on 09/05/2025. An Immediate Jeopardy (IJ) was identified on 09/24/2025 at 9:45 a.m. The IJ template was provided to the facility on [DATE] at 11:05 a.m. While the IJ was removed on 09/25/2025 at 5:33 p.m., the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of accidents, injuries, and death due to lack of appropriate interventions in place.Findings included: 1. Record review of Resident #6's face sheet, dated 09/24/2025, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #6 had diagnoses which included cerebral infarction (occurs when blood flow to part of the brain is blacked leading to tissue death), schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges) conversion disorder with seizures or convulsions (mental health condition in which individuals experience neurological symptoms without any detectable neurological or medical cause),acquired absence of left leg below the knee (loss of leg below the knee) and hemiplegia (total paralysis or severe loss of muscle function on one side of the body) following cerebral infarction . Record review of Resident #6's quarterly MDS Assessment, dated 06/10/2025, indicated she had a BIMS score of 14 and diagnoses of hemiplegia, cerebral infarct, schizophrenia and seizure disorder. The assessment indicated Resident #6 was dependent for transfer and needed supervision for locomotion in manual wheelchair for 50 feet. Record review of Resident #6's quarterly MDS Assessment, dated 09/10/2025, indicated she had a BIMS score of 12 and diagnoses of hemiplegia, cerebral infarct, schizophrenia and seizure disorder. The assessment indicated Resident #6 was dependent for assistance of 1 to 2 people for transfer and dependent locomotion in manual wheelchair for 50 feet. Record review of Resident #6's care plan with a target date of 11/18/2025 indicated Resident #6 had a diagnosis of schizophrenia and was at risk of increased behaviors. Interventions included intervene and monitor resident for increased agitation, anger, verbal and physical aggression, and document episodes of behavior. Record review of Resident #6 police report dated 08/21/25 indicated a crime incident of assault, the victim was Resident #6, and she notified the officer that Resident #25 entered her room put his hand under her leg and rubbed his hand on her leg. She said Resident #25 stated, “I'm sorry it just feels so good to feel skin so soft.” Resident #6 indicated she felt it was a sexual nature, and she wished to file a report. The report indicated a non-consent form was signed. Record review of Resident #25's face sheet, dated 09/24/2025, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #6 had diagnoses which included hemiplegia following cerebral infarction, morbid obesity (having too much body fat which increases the risk of health problems), cerebral infarction, post- traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) and convulsions. Record review of Resident #25's quarterly MDS Assessment, dated 02/13/2025, indicated he had a BIMS score of 15 indicating cognitively intact. The assessment indicated Resident #25 required dependence (helper does all the effort) of 1 or 2 persons to transfer from bed to chair and independent of locomotion in a motorized scooter. Record review of Resident #25's quarterly MDS Assessment, dated 09/19/2025, indicated he was cognitively independent and had no long-term or short-term memory problem. The assessment indicated Resident #25 required dependence of 1 or 2 persons to transfer from bed to chair and independent of locomotion in a motorized scooter. Record review of Resident #25's care plan with a revision date of 08/22/2025 indicated Resident #25 had inappropriate sexual behaviors and was at risk of further episodes and injury. The Care plan indicated Resident #25 had a history of allowing an intellectually challenged resident perform oral sex on him in the dining room and on 08/21/25 was witnessed rubbing on the leg of another resident that was unwanted. Interventions included to redirect during episodes of inappropriate sexual behavior and document in the clinical record, firmly approach the resident that behaviors are not acceptable. The care plan indicated on 08/21/25 Resident #25 was sent out for a psychiatric evaluation, was on 1 on 1 monitoring and psychiatric referral made in house by the nurse practitioner and discharge planning. Resident #25's care plan did not include interventions to prevent further sexual abuse episodes on other residents by Resident #25. Record review of a Resident-to-Resident incident report, dated 08/21/2025 indicated an incident was reported that included Resident #25 and Resident #6 with the allegation of abuse and the police were notified. Record review of the facility's Provider Investigation Report, dated 08/28/2025, incident category as other and other specified as a resident-to-resident incident signed by the Administrator on 08/28/2025. The PIR indicated the incident occurred on 08/21/2025 at 10:00 a.m. PIR indicated Resident #6 stated Resident #25 rubbed on her leg and she did not want the touching on her leg. The incident was witnessed by Hospice RN, Residents were separated immediately, and Resident #25 was placed on 1:1 supervision. The physician was contacted and gave orders for Resident #25 to be transferred to the emergency room. Psychiatric service was contacted and performed an evaluation on Resident #25. Reeducated staff on abuse and neglect and increased rounding. The SW conducted psychosocial evaluations with no concerns, social worker conducted safe surveys with no concerns and the IDT team met and discussed the incident and updated care plans. Investigation findings were confirmed. Record review of an email from the Administrator on 08/22/25 to the MDS Contractor indicated,” Please update the following Care Plans: Resident #6 made sexual abuse allegations on 08/21/25, against Resident #25. Resident #25 was witnessed rubbing on the leg of patient and was unwanted. Resident #25 was sent out for psych eval and on 1on 1 monitoring. Psych Referral made in-house to NP. …” During an observation and interview on 09/22/25 at 10:00 a.m., Resident #25 named in the allegation was lying in bed, he denied sexual abuse of Resident #6. He said he brought his friend Resident #6 a cup of coffee and she was on the verge of tears. Resident #25 said Resident #6 told him no one liked her and he said everyone here likes you and rubbed her lower leg on top of the covers. Resident #25 said he did not sexually touch anyone inappropriately. He said he was comforting his friend. Resident #25 said a nurse came into the room, did not ask any questions and made a mountain out of a mole hill. Resident #25 said he was sent to the hospital to be evaluated and had not been to Resident #6's room since the incident. During an observation and interview on 09/22/25 at 10:20 a.m., Resident #6 named in the allegation, was up in her scooter with a left, below knee amputee, she said she was treated well, received needed care, call lights answered timely, and she denied abuse/ neglect. Resident #6 said she felt safe in the facility and was comfortable reporting concerns to the nurse. She said Resident #25 was not allowed in her room. Resident #6 said the day of the incident (08/21/25) Resident #25 brought her coffee and that it was fine, but she said he started rubbing her right lower leg under the covers. She said she told him, ”I don't like that, she said she did not say stop.” Resident #6 said a nurse came into the room and Resident #25 stopped and left the room. She said I was very upset when it happened but now felt safe in the facility. During an interview on 09/23/25 at 4:30 a.m., Resident #6 said Resident #25 said her skin was so soft he could not help himself when he rubbed her leg the day of the incident (08/21/25). During an interview on 09/23/25 at 12:00 p.m., LVN X said she did not witness the incident on 08/21/25 with Resident #6 and Resident #25. She said the Hospice RN notified her she witnessed Resident #25 rubbing Resident #6's leg under the covers of her bed. LVN X said Resident #25 said Resident #6 asked me to come into her room. LVN X said Resident #25 said Resident #6 said no one loved her and he touched her leg. LVN X said Resident #25 normally gets up early, goes outside for the morning then back to bed but not normally into other resident rooms. She said there was no reason for him to visit down Resident #6's hall. LVN X said Resident #6 said she did not give Resident #25 consent to touch her. She immediately notified the DON, ADON and Administrator. LVN X placed Resident #25 on 1 on 1 monitoring after the incident. She said that meant constant monitoring, eyes and ears on Resident #25, a CNA sat outside his room and stared at him in his room alone. She completed an assessment on both residents with no injury noted. LVN X said Resident #25 was sent out to the hospital later that night. She said Resident #25 required 2 CNAs to get Resident #25 out of bed and transferred to his scooter. LVN X said Resident #25 was not allowed to go to Resident #6's room. She was in-serviced prior to the incident on abuse/ neglect and sexual abuse prevention. She said after the incident she was in-serviced on abuse/ neglect and sexual abuse prevention. During a phone interview on 9/23/25 at 4:00 p.m., the Hospice RN said on 08/21/25 she was in Resident #6's room visiting her roommate and heard Resident #25 say “I want to feel your soft skin”, she said Resident #25 had his hand under Resident #6's covers. The Hospice RN said Resident #25 saw her, stopped touching Resident #6 and left the room. She immediately reported the incident to LVN X and then wrote her statement. She said she did not say anything to Resident #25. The Hospice RN said she heard LVN X ask Resident #6 if she asked Resident #25 to do that and she said no and cried. 2. Record review of Resident #1's face sheet, dated 09/23/2025, indicated a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included cerebral palsy (congenital disorder of movement, muscle tone, or posture due to abnormal brain development), aphasia (disorder that affects language after a stroke), dysphagia (difficulty swallowing after a stroke), diabetes (a chronic condition that affects the way the body processes blood sugar), developmental disorder, and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #1's quarterly MDS Assessment, dated 2/09/2025, indicated she was sometimes able to make herself understood and usually understood others. She was not assessed for the brief interview for mental status because she is rarely/never understood. She had an active diagnosis of psychotic disorder and depression in the last 7 days. She had no behaviors identified within the 7 days look back period. Record review of Resident #1's quarterly MDS Assessment, dated 5/08/2025, indicated she was sometimes able to make herself understood and usually understood others. She was unable to complete the brief interview for mental status. She had an active diagnosis of psychotic disorder and depression in the last 7 days. She had no behaviors identified within the 7 days look back period. Record review of Resident #1's quarterly MDS Assessment, dated 8/08/2025, indicated she was sometimes able to make herself understood and usually understood others. She had severe cognitive impairment, identified with a BIMS score of 3. She had an active diagnosis of psychotic disorder and depression in the last 7 days. She had no behaviors identified within the 7 days look back period. Record review of Resident #1's care plan revision dated 11/11/2024 indicated Resident #1 had physical aggression. Interventions included to Intervene before agitation escalates; guide away from source of distress; Engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later, administer medications as order and document side effects and effectiveness, assess and address for contributing sensory deficits and monitor/document/report as needed any s/s of resident posing danger to self and others, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #1 had an updated or revised care plan for aggressive behaviors during a resident-to-resident aggression with two other residents (Resident #2 and #3) on 03/19/2025. Record review of Resident #1's care plan revision dated 8/13/2025 indicated Resident #1 had physical aggression. Interventions included to place on 1:1 monitoring for 2 hours and separate from another resident, intervene before agitation escalates; guide away from source of distress; Engage calmly in conversation; if response was aggressive, staff to walk calmly away, and approach later, administer medications as order and document side effects and effectiveness, assess and address for contributing sensory deficits and monitor/document/report as needed any s/s of resident posing danger to self and others, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #1 had an updated or revised care plan for aggressive behaviors during a resident-to-resident aggression with Resident #2 on 07/24/2025. Record review of Resident #1's care plan dated 9/04/2025 indicated Resident #1 had inappropriate behaviors. Interventions included monitoring and charting behaviors every shift and report progress to MD, observing for early warning signs of behavior - approach in a calm manner, call by name, remove from unwanted stimuli and provide psych consult per order. The care plan did not indicate Resident #1 had an updated or revised care plan for aggressive behaviors during a resident-to-resident aggression with Resident #4 on 09/05/2025. Record review of a progress notes/incident report for physical aggression, dated 03/19/2025, indicated an incident was reported that included Resident #1 had fallen and scratched Resident #2 on the leg during the fall. Resident #1 got herself back in her wheelchair and then she spit on Resident #2 and scratched Resident #3. Resident #1 was placed on 1:1 monitoring immediately and was later released. Resident #2 had a scratch on her right forearm. Resident #3 had a scratch on her left leg and 0.5cm x 0.5cm skin tear to left index finger knuckle area. Psych NP of Resident #1 notified of incident and new medication ordered for agitation and anxiety. Record review of the facility's Provider Investigation Report dated 3/19/2025, incident category as resident-to-resident abuse signed by the Administrator on 03/25/2025. PIR indicated the incident occurred 03/19/2025 at 11:13 a.m. PIR indicated Resident #1 scratched Resident #2 and Resident #3. ADON provided head to toe assessment to Resident #2 and #3 injuries of Resident #2 sustained scratch to forearm and Resident #3 sustained scratch to left leg and hand. Provider response after the incident included, residents separated, Resident #1 placed on 1:1 monitoring, Resident #1 referred to psych, head to toe assessments on all involved residents, incident/accident report completed, safe surveys conducted, Resident #2 and #3 treated in house, behavioral monitoring initiate on Resident #1, abuse and neglect in-services initiated, MD/family notified, ordered labs drawn on Resident #1. Resident abuse confirmed. Record review of Resident #2 skin assessment dated [DATE] indicated Resident #2 had a 17 cm x 1cm skin tear to right forearm. No active bleeding but red in color, no swelling, and no bruising. Record review of Resident #3 skin assessment dated [DATE] indicated Resident #3 had a scratch on her left leg and 0.5cm x 0.5cm skin tear to left index finger knuckle area and bilateral legs had multiple old scarring and multiple scattered areas of discoloration to bilateral arms. During an observation and interview on 09/23/2025 at 1:40 p.m., Resident #2 was sitting in a wheelchair in the dining area, she said that she and Resident #1 had several incidents, she pointed to 2 bruises to left forearm, consistent with being pinched, and said Resident #1 had pinched her causing the bruises. She said that she tries to stay away from Resident #1, so she does not scratch or pinch her. During an observation and interview on 09/23/2025 at 1:45 p.m., Resident #3 was sitting in a wheelchair in the dining area, she denied anyone scratching or hitting her and she denied hitting anyone. Resident #3 was confused and unable to answer more than a few questions. During an interview on 09/24/2025 at 1:50 p.m., LVN A said that Resident #1 and Resident #2, and Resident #3 have a love hate relationship. She said some days they request to sit together and communicate and other days they are mad at each other. LVN A said on the days they are mad or upset that staff try to intervene and separate them to keep residents safe but sometimes the behaviors onset quickly and staff are unable to intervene to prevent incidents. LVN A said that if resident to resident altercations occur that the staff separate the residents, and the aggressor is placed on 1:1 monitoring for 2 hours or until released by psych or transferred to hospital. LVN A said she would assess the involved residents and notify the NP/MD and follow the orders provided. Record review of a progress notes/incident report for physical aggression, dated 07/24/2025, indicated the nurse heard Resident #1 yelling very loudly. Nurses responded to the incident in the dining room. Nurse could see down the hall into the dining room, Resident #1 and Resident #3 were both swing arms at each other. Upon nurses' arrival at the dining room, residents were no longer hitting each other but Resident #3 was holding Resident #1's left hand and would not let go. This resident continued to yell. Resident #3 refused to let go of Resident #1's hand. The nurse was eventually able to ungrasp the other resident's hand and then separate residents. Both residents were evaluated, finding no injuries. Resident #3 placed on 1:1 behavior monitoring for 2 hours. Record review of the facility's Provider Investigation Report, dated 07/24/2025, incident category as resident-to-resident abuse signed by the Administrator on 07/25/2025. The PIR indicated the incident occurred on 07/24/2025 at 7:00 a.m. The PIR indicated Resident #3, and Resident #1 were hitting each other and then Resident #3 grabbed Resident #1's hand and would not let go. LVN A performed a head-to-toe assessment on both residents, no injuries indicated. Provider response after the incident included, residents separated, Resident #3 placed on 1:1 monitoring for 2 hours, head-to-toe assessments on all involved residents, incident/accident report completed, safe surveys conducted, abuse and neglect in-services initiated, Psych NP notified, MD/family/hospice notified. Resident abuse confirmed. Record review of a progress notes/incident report for physical aggression, dated 09/05/2025, indicated LVN A witnessed Resident #1 hit Resident #4 twice in her right arm with closed fist, unprovoked as she was passing by her. Resident #4 did not hit the other resident back. Resident #1 was removed from area and placed on 1:1 monitoring. Resident #4 was able to verbalize that she did not do anything to Resident #1 to provoke her to hit her. Resident #4 denied any pain in her arm at this time. DON, Administrator, NP and Psych NP notified of incident. Resident #1 continued with behaviors during 1:1 monitoring and Psych NP ordered Resident #1 Hydroxyzine 25mg 1 tablet by mouth every 6 hours as needed x 14 days. Record review of the facility's Provider Investigation Report, dated 09/05/2025, incident category as resident-to-resident abuse signed by the Administrator on 09/10/2025. The PIR indicated the incident occurred on 09/05/2025 at 4:00 p.m. The PIR indicated LVN A witnessed Resident #1 hit Resident #4 on the arm. LVN A performed a head-to-toe assessment on both residents, no injuries identified. Provider response after the incident included, residents separated immediately, Resident #1 placed on 1:1 monitoring for 2 hours, head-to-toe assessments on all involved residents, incident/accident report completed, safe surveys conducted, care plans updated, abuse and neglect in-services initiated, Psych NP and MD/family notified. Resident abuse confirmed. During an interview on 09/24/2025 at 12:45 p.m., Resident #4 said that she was hit by Resident #1 on the arm when she was coming down the hall. She said that she was not hurt and did not hit her back. She said that she knows not to hit other residents and to notify nurse if someone hits her. During an interview on 09/24/2025 at 2:10 p.m., LVN A said that Resident #1 and Resident #4 were in the hallway, and she witnessed Resident #1 hit Resident #4 on the arm. She said that Resident #4 did not provoke the incident and did not hit Resident #1 back. She said Resident #1 gets upset when she cannot talk to her sister on the phone or in person, and this day her family member was out of town and unable to be reached and Resident #1 started having behaviors after not being able to talk to her family member. She said that she goes out with her family member and stays with her family member overnight and when those visits are unable to be arranged Resident #1 gets upset and acts out. She said that Resident #1 was monitored 1:1 after the incident. 3. Record review of Resident #2's face sheet, dated 09/23/2025, indicated a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges), Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), manic episodes, intellectual disabilities, diabetes type 1 (chronic condition in which the pancreas produces little or no insulin), dementia (loss of cognitive functioning), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #2's annual MDS Assessment, dated 1/17/2025, indicated she was able to make herself understood and understood others. She was intact cognitively, identified with a BIMS score of 14. She had an active diagnosis of anxiety disorder, depression, bipolar disorder, and schizophrenia in the last 7 days. She had no behaviors identified within the 7 days look back period. Record review of Resident #2's care plan revision dated 1/16/2024 indicated Resident #2 had inappropriate behaviors. Interventions included to activities, explain procedures using terms gestures residents can understand, monitor and chart behaviors every shift and report progress to MD, observe for early warning signs of behavior - approach in a calm manner, call by name, remove from unwanted stimuli, give medications per order - monitor labs - report results to MD, and consult psychiatric/ psychogeriatric as indicated. Record review of Resident #2's care plan dated 5/19/2025 indicated Resident #2 had physical aggression from another resident. Interventions included analyzing times of day, places, circumstances, triggers, and what de-escalates behavior and document, assessing and addressing for contributing sensory deficits, monitor/document/report as needed any s/s of resident posing danger to self and others, when the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later and administer medications as ordered, monitor/document for side effects and effectiveness, and psychiatric/psychogeriatric consult as indicated. The care plan did not indicate Resident #2 had an updated or revised care plan for receiving aggressive behavior from another resident during a resident-to-resident aggression on 03/19/2025. 4. Record review of Resident #3's face sheet, dated 09/23/2025, indicated a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses which included vascular dementia (changes in thinking and memory that occur when there isn't enough blood flow to part of the brain), diabetes (a chronic condition that affects the way the body processes blood sugar), stroke, dementia (loss of cognitive functioning), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #3's quarterly MDS Assessment, dated 3/14/2025, indicated she was sometimes able to make herself understood and sometimes understood others. She was moderately impaired cognitively, identified with a BIMS score of 11. She had an active diagnosis of depression in the last 7 days. She had no behaviors identified within the 7 days look back period. Record review of Resident #3's quarterly MDS Assessment, dated 6/12/2025, indicated she was sometimes able to make herself understood and sometimes understood others. She was severely impaired cognitively, identified with a BIMS score of 6. She had an active diagnosis of depression in the last 7 days. She had behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) which occurred 1 to 3 days within the 7-day look back period. The care plan did not indicate Resident #3 had an updated or revised care plan for receiving aggressive behavior from another resident during a resident-to-resident aggression on 03/19/2025 and 07/24/2025. 5. Record review of Resident #4's face sheet, dated 09/23/2025, indicated a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included psychosis (severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality), diabetes (a chronic condition that affects the way the body processes blood sugar), delirium (confusion that happens when illness, changes in your environment or other factors put too much stress on your brain), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #4's quarterly MDS Assessment, dated 8/30/2025, indicated she was able to make herself understood and understood others. She was moderately impaired cognitively, identified with a BIMS score of 8. She had an active diagnosis of depression and psychotic disorder in the last 7 days. She had no behaviors identified within the 7-day look back period. Record review of Resident #4's care plan revision dated 5/30/2025 indicated Resident #4 has potential to be physically aggressive related to anger, and poor impulse control. Interventions included behavior de-escalation by removing her from the issue as it is happening, analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document, assessing and addressing for contributing sensory deficits, assessing and anticipating resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc., give the resident as many choices as possible about care and activities and psychiatric/psychogeriatric consult as indicated. The care plan did not indicate Resident #4 had an updated or revised care plan for receiving aggressive behavior from another resident during a resident-to-resident aggression on 09/05/2025. During an interview on 09/24/2025 at 8:55 a.m., the Administrator said that all incidents and allegations are discussed during morning meetings (including herself, administrator, department heads) and if care plans need to be updated that she emailed the VP of Clinical Reimbursement, a MDS Contractor and the care plans and interventions were updated remotely. She said that it appears that no one was verifying that the emails were received, and the tasks were completed. She said she is unsure why the care plans were not updated as requested and if the care plans were not updated or revised, the care plan would not reflect the current resident's needs. She stated new interventions should be added to the care plan regarding recurrent resident-to-resident altercations. She said the DON should have been assigned the responsibilities of ensuring the care plan was updated when the in-house MDS coordinator left. Record review of an undated facility policy titled, “Policy: Comprehensive Care Planning & IDT Participation” indicated, “…. To ensure that every resident at … has an individualized, comprehensive care plan developed and implemented by the Interdisciplinary Team (IDT) in compliance with federal and Texas state regulations. … 3. Behavioral Care Plans must be initiated and completed by the next business day following identification of behaviors. … Social services and Nursing Department are responsible for updating acute or new care plans identified between quarterly Care Plan Review …” An Immediate Jeopardy (IJ) was identified on 09/24/2025 at 9:45 a.m. The IJ template was provided to the facility on [DATE] at 11:00 a.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The following Plan of Removal (POR) submitted by the facility was accepted on 9/25/25 at 10:45 a.m.: Resident-Specific Interventions - 09/24/2025 - Completed by VP of Clinical Reimbursement Resident #1's care plan was updated 09/24/25 psych NP discontinued Buspirone 5 mg with new order for Buspirone 20 mg every evening. Resident #2, #3 and #5 care plans updated 09/24/2025 regarding receiving abuse

Based on observations, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to the abuse coordinator for immediate intervention and all alleged violations involving abuse were reported no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or bodily injury, to the administrator of the facility and to other officials, including the State Survey Agency in accordance with State law through established procedures for 3 of 25 residents (Resident #5, #7 and #8) reviewed for abuse. 1. The facility failed ensure ST R reported a witnessed allegation of physical and verbal abuse immediately to the Abuse Coordinator approx. 1.5 weeks prior to 7/1/2025. ST R witnessed CNA M tell Resident #5 to sit you ass down multiple times and then forcefully push Resident #5 into a chair approx. 1.5 weeks prior to 7/1/2025. The Abuse Coordinator became aware of the incident on 7/3/2025 during a facility investigation and staff interviews regarding another abuse allegation of Resident #5. 2. The facility failed to ensure LVN Z reported an allegation of abuse immediately to the Abuse Coordinator on 12/29/24. LVN Z documented on 12/29/24 at 8:16 p.m. that CNA Y observed Resident #7 hit Resident #8. The DON became aware of the incident on 12/30/25 upon review of progress notes and subsequently reported the allegation to the abuse coordinator. 3. The facility failed to ensure LVN XX reported an allegation of abuse immediately to the Abuse Coordinator on 05/18/2025. An Immediate Jeopardy (IJ) was identified on 09/24/2025 at 9:45 a.m. The IJ template was provided to the facility on [DATE] at 11:05 a.m. While the IJ was removed on 09/25/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.Findings included: 1. Record review of Resident #5's face sheet, dated 09/23/2025, indicated a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 had diagnoses which included diffuse traumatic brain injury (widespread damage across multiple areas of the brain), hypertension (a condition in which the force of the blood against the artery walls is too high), encephalopathy (group of conditions that cause brain dysfunction, which can manifest as confusion, memory loss, personality changes), dementia (loss of cognitive functioning), lack of coordination, cognitive communication deficit, and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #5's quarterly MDS Assessment, dated 5/04/2025, indicated he rarely/never made himself understood and sometimes understood others. He was not assessed for the brief interview for mental status because he is rarely/never understood. He had no behaviors identified within the 7-day look back period. Record review of Resident #5's care plan revision dated 7/03/2025 indicated Resident #5 had an incident of confabulation and had a potential for further episodes of confabulation and confabulation triggered behaviors. Interventions included allow residents to verbalize feelings during episodes of confabulation - gently reorient and maintain safety, orient/re-orient resident daily and PRN, encourage to attend activities of choice, and report to MD/RP as needed and document episodes of confabulation in the clinical record. Record review of the facility's Provider Investigation Report dated 7/01/2025, incident category as abuse signed by the Administrator on 7/11/2025. PIR indicated the incident occurred 7/01/2025 at 7:00 p.m. on the secure unit. PIR indicated during staff interviews ST R said she witnessed CNA M be verbally and physical aggressive with Resident #5 approximately 1.5 weeks ago. CNA M was heard telling Resident #5 to sit you ass down and witnessed forcefully pushing him into the chair and pushing his chair forcefully under the table. LVN X provided head to toe assessment to Resident #5 with no injuries noted. Provider response after the incident included, employee suspended immediately, head to toe assessments on all residents in the secure unit, safe surveys conducted, employee statements collected, abuse and neglect in-services initiated, care plan updated, psych NP notified, MD notified, no family to notify, and local police contacted. Resident abuse confirmed. Employee terminated. During an interview on 09/24/2025 at 2:00 p.m., ST R said she had witnessed CNA M physically and verbally abuse Resident #5 sometime in late June 2025 when she heard CNA M tell Resident #5 to sit you ass down multiple times and then forcefully push Resident #5 into a chair and push him up to the table. ST R said she reported this incident late, when she was being interviewed regarding another incident with Resident #5. She said at the time it happened she felt uneasy about the incident and would not want her family treated that way. She said that she reported the incident to clear her consciousness and knew it should have been reported when she first witnessed the incident. She said she was suspended and received disciplinary actions regarding not reporting the abuse allegation immediately and re-educated prior to returning to work. She said moving forward that any abuse allegations witnessed or reported to her she would report it immediately to the administrator. During an interview on 9/23/2025 at 1:30 p.m., LVN X said she recalled the assessed Resident #5 after the incident and did not identify any injuries. She said that if she was notified of an abuse allegation, she would make sure the resident is safe and then immediately report to the Administrator/Abuse Coordinator. She said if she witnessed a resident being abused that she would intervene and remove the abuser and keep the resident safe, notify the AC and/or send the staff member home and if resident to resident keep separated for safety. During an interview on 09/24/2025 at 8:30 a.m., the Administrator said she was made aware of the witnessed abuse allegation of Resident #5 when she was taking statements from employees on 07/03/2025 during an ongoing investigation with abuse allegation of Resident #5. She said ST R told her on 07/03/2025 that she had witnessed CNA M be verbally and physically abusive to Resident #5 approx. 1.5 weeks prior. She said ST R stated she did not report the allegation at the time because she was confused about the situation, did not want to get anyone in trouble or cause drama. She said ST R was suspended for not reporting the incident immediately. She said she did not report the new abuse allegation to the state but did investigate the allegation while she was investigating the current abuse allegation of Resident #5. She said she included the information in the PIR submitted and did not realize the new allegation should have been reported separately. Record review of ST R's personnel record indicated she was trained on abuse and reporting abuse on 06/29/2025. 2. Resident #7Record review of Resident #7's face sheet dated 09/24/2025 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included hemiplegia (one-sided paralysis or weakness) and hemiparesis (partial one-sided weakness) following cerebral infarction (stroke) affecting left non-dominant side, aphasia (communication disorder), schizoaffective disorder (mental health condition), major depressive disorder (mood disorder), and (intense, persistent worry and fear about everyday situations). Record review of Resident #7's quarterly MDS assessment dated [DATE] indicated she was sometimes able to make herself understood and usually understood others. She was cognitively intact (BIMS-14). There were no behaviors noted. Record review of Resident #7's care plan dated 08/11/2025 indicated Resident #7 had the potential for physical aggression related to a diagnosis of schizoaffective disorder. Interventions included psychiatric consult as indicated and when the resident becomes agitated-intervene before agitation escalates, guide away from source of distress. Resident #8Record review of Resident #8's face sheet dated 09/24/2025 indicated he was a [AGE] year old male, admitted on [DATE], and his diagnoses included unspecified convulsions (involuntary contractions and spasms that do not have a specific diagnoses), HTN (high blood pressure), HDL (high levels of fats), acute hepatitis (inflammation of liver), COPD (chronic lung disease), depression (mood disorder) psychoactive substance abuse (harmful or hazardous use of substances that affect mental processes), schizoaffective disorder (mental health condition), hallucinations (hear, see, smell, taste or feel things that are not present), and suicide ideation (thoughts of suicide). Record review of Resident #8's quarterly MDS assessment dated [DATE] indicated he was able to make himself understood and understood others. He had moderate cognitive impairment (BIMS-12). Record review of Resident #8's care plan dated 10/27/2024 indicated he was at risk of mani episodes and increased behavior related to a diagnosis of schizophrenia. Interventions included administering medications as ordered, monitor for delusions and hallucinations, monitor for increased aggression, psych consult as needed, and remove resident for increased stimuli during behavioral episodes. Record review of Resident #8's nurse note dated 12/29/2024 at 2:00 p.m., completed by LVN Z, indicated she was notified by CNA Y of Resident #7 and Resident #8 were involved in a physical altercation. Resident #7 was hitting Resident #8. CNA Y directed Resident #7 to stop hitting Resident #8. Resident #7 stopped hitting Resident #8. Resident #8 stated he was OK. He said, I'm not worried about that b****. That b**** crazy. I am not worried about her. She better go on. Resident #7 continued to roll up to Resident #8 and tried to hit him again. LVN Z told them to stop and do not hit each other. LVN Z told them that this type of behavior was unacceptable. Further review revealed LVN Z did not document notification of the alleged abuse to the Administrator or the DON. Record review of LVN Z's undated statement indicated she was notified by CNA Y that Resident #7 had an altercation with resident #8. Resident #7 was around Resident #8 and hit him with her hand. Resident #8 said he was OK. CNA Y said she told Resident #7 to stop, and she did. CNA Y said the altercation was because Resident #8 owed Resident #7 $20. LVN Z said she was not around during the incident. Resident #7 was in her room resting. LVN Z was in the hall pulling medications and asked Resident #8 what happened, and he said he was not worried about that bitch. She was crazy. Resident #7 came back towards Resident #8, and she told him to move away. Resident #7 was monitored for the rest of the night for behaviors. Record review of CNA Y's statement dated 12/30/2024 indicated on 12/29/24 around 1:15 p.m., a resident came down the hall and pushed a barrel into Resident #7. Resident #8 tried to stop her by pulling on the handle of the chair. She turned around and started hitting him with a bag of food. Resident #7's son came around the corner and tried to diffuse the problem, but she kept going on. When Resident #8 said he did not owe her $20 she picked up the wet floor sign and tried to hit him and when she could not hit him with the wet floor sign, she raised her leg to kick him. During an interview on 09/23/2025 at 10:00 a.m. the DON said she became aware of the alleged abuse between Resident #7 and Resident #8 that occurred on 12/29/24, when she reviewed the incident written by LVN Z, on 12/30/24. She said Resident #7 was placed on 1 to 1 immediately until cleared by psych on 12/30/24. She said Resident #7 and Resident #8 were assessed with no injuries. She said LVN Z was trained upon hire to report abuse and allegations of abuse immediately to the Administrator. She said LVN Z was terminated due to not reporting immediately. During an interview on 09/24/2025 at 12:27 p.m., previous Administrator U said he did not confirm the incident on 12/29/24 as abuse. He said he recalled Resident #7 swung a shopping bag at Resident #8 because Resident #8 had grabbed the back of her wheelchair. He said LVN Z did not report the incident immediately to him on 12/2920/24 as required and they were terminated. During an interview on 09/25/2025 at 9:28 a.m., LVN Z said she did not see the abuse between Resident #7 and Resident #8 and the reason she did not report it to Administrator U. She said CNA Y reported the alleged abuse to her on 12/29/2024. She said she was called in to the facility on [DATE] and gave her statement. She said she could not recall being trained to report abuse immediately to the administrator. 3. Resident #2Record review of Resident #2's face sheet, dated 09/23/2025, indicated a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges), Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), manic episodes, intellectual disabilities, diabetes type 1 (chronic condition in which the pancreas produces little or no insulin), dementia (loss of cognitive functioning), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #2's quarterly MDS Assessment, dated 4/05/2025, indicated she was able to make herself understood and understood others. She was intact cognitively, identified with a BIMS score of 13. She had an active diagnosis of anxiety disorder, depression, bipolar disorder, and schizophrenia in the last 7 days. She had no behaviors identified within the 7 days look back period. Record review of Resident #2's care plan revision dated 1/16/2024 indicated Resident #2 had inappropriate behaviors. Interventions included to activities, explain procedures using terms gestures residents can understand, monitor and chart behaviors every shift and report progress to MD, observe for early warning signs of behavior - approach in a calm manner, call by name, remove from unwanted stimuli, give medications per order - monitor labs - report results to MD, and consult psychiatric/ psychogeriatric as indicated. Record review of Resident #2's care plan dated 5/19/2025 indicated Resident #2 had physical aggression from another resident. Interventions included analyzing times of day, places, circumstances, triggers, and what de-escalates behavior and document, assessing and addressing for contributing sensory deficits, monitor/document/report as needed any s/s of resident posing danger to self and others, when the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later and administer medications as ordered, monitor/document for side effects and effectiveness, and psychiatric/psychogeriatric consult as indicated. Resident #3Record review of Resident #3's face sheet, dated 09/23/2025, indicated a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses which included vascular dementia (changes in thinking and memory that occur when there isn't enough blood flow to part of the brain), diabetes (a chronic condition that affects the way the body processes blood sugar), stroke, dementia (loss of cognitive functioning), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #3's quarterly MDS Assessment, dated 3/14/2025, indicated she was sometimes able to make herself understood and sometimes understood others. She was moderately impaired cognitively, identified with a BIMS score of 11. She had an active diagnosis of depression in the last 7 days. She had no behaviors identified within the 7 days look back period. Record review of a progress notes/incident report for physical aggression, dated 05/18/2025, authored by LVN XX indicated an incident was reported that included Resident #2 and Resident #3 sitting in dining room yelling at each other. Residents separated. No injuries were identified. Record review of the facility's Provider Investigation Report, dated 05/18/2025, incident category as resident-to-resident abuse signed by the Administrator on 05/23/2025. The PIR indicated the incident occurred on 05/17/2025 at 6:30 a.m. The PIR indicated Resident #3 scratched and pulled Resident #2's hair, who was trying to prevent her from getting coffee. LVN YY performed a head-to-toe assessment on both residents, Resident #2 received scratch to left forearm. Provider response after the incident included, residents separated, head-to-toe assessments on all involved residents, incident/accident report completed, employee statements, safe surveys conducted, care plans updated, abuse and neglect in-services initiated, psych referral completed, and MD/family notified. Resident abuse confirmed. An attempted telephone interview on 09/24/2025 at 7:45 a.m. with LVN XX was unsuccessful. During an interview and record review of provider investigation report on 09/24/2025 at 8:45 a.m., the Administrator clarified that the incident between Resident #2 and Resident #3 occurred on 5/18/2025 at 8:00 a.m. but she was not made aware of the allegation until she arrived at work on Monday 05/19/2025. She said Resident #2 notified her on 05/19/2025 of the incident and showed her the scratch that she received during the incident. She said she began investigating at that time and reported the allegation to the state once the incident was confirmed. She said that the allegation was reported late, and she is aware that all abuse allegations are to be reported to the state agencies within 2 hours of the incident and the delayed reporting could be other residents at risk for harm or abuse. Record review of the facility's Abuse and Neglect policy dated June 2023 indicated . All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee. All allegations of abuse will be reported to DADS immediately after the initial allegation is received. An Immediate Jeopardy/Immediate Threat was identified on 09/24/2025 at 9:45 a.m. The Administrator was notified of the Immediate Jeopardy on 09/24/2025 at 11:00 a.m. The IJ template was provided to the facility on [DATE] at 11:05 a.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal for Immediate Jeopardy was accepted on 9/25/25 at 10:45 am. and reflected the following: Actions for Resident Involved: Resident #7 / Resident #8: Resident #7 struck Resident #8 with shopping bag; risk of physical harm. Resident #5: Subjected to verbal and physical abuse by CNA M. Resident #3 / Resident #2: Resident #3 scratched Resident #2; delay in reporting placed Resident #2 at risk of further harm. All residents in facility: Placed at risk due to systemic failure to report abuse allegations immediately. Immediate Actions Completed (as of 9/24/2025): Residents assessed for injuries; psychosocial evaluations completed on 12/30/2024 by the Director of Nursing, Skin assessment completed by Treatment Nurse. Resident #7 placed on 1:1 monitoring on 12/30/2024LVN Z terminated for failure to report abuse-1/3/2025. Resident #5CNA M was terminated for abusive behavior on 7/7/2025.ST R suspended and re-educated on 7/3/2025. Facility-wide in-service provided to staff on abuse/neglect reporting policy, including immediate reporting to Abuse Coordinator and State Agency. 12/30/2024-by the DON; 1/15/2025-by the DON; 7/1/2025-by the Administrator; 7/7/2025-by the DON; 7/9/2025-by the DON; 7/22/2025-by the Administrator. Systemic Actions to Prevent Recurrence: Start date: 9/24/25 Completion date: 9/24/25 Responsible: Administrator / Designee DON (Director of Nursing) and Administrator will be educated by CNO (Chief Nurse Officer) and VP of Operations on Abuse, neglect and exploitation, reporting guidelines. All staff will receive mandatory re-education with verbal discussion and signing of in-service sign-in sheet. A post-quiz will be used to determine understanding of timely reporting of any types of abuse and neglect to the Abuse coordinator and or designee along with the appropriate departmental supervisor. 9/24/2025 Abuse reporting flowchart posted in nurse stations, break rooms, med rooms. 9/24/2025 Abuse allegations are logged and reviewed weekly by Admin/DON/designee. Ongoing competency checks added to new hire orientation and annual training. Progressive discipline reinforced for any failure to report. Monitoring/Accountability: Review of 24-hour reports, progress notes, incident reports and any grievances to identify any possible abuse, neglect, or exploitation that may have occurred and on Monday for the weekend. By the Administrator/Designee and DON. Random weekly staff interviews for four weeks or as needed to verify knowledge of reporting procedures Random safe surveys with residents for four weeks or as needed to be completed by Admin/SW/Designee QA Committee will review abuse investigations in the daily standup meetings, and the Governing Body will review monthly. Responsible Staff:Administrator / designee will ensure immediate investigations and reports to HHSC Administrator/ DON will ensure compliance, staff training, and monitoring audits. QA Committee will have oversight of systemic compliance and sustainability. Physician Notified of Immediate Jeopardy 9/24/2025 Section 3 - Timeliness Immediate protective actions completed as of 9/24/2025 Terminations, suspensions, and staff in-servicing completed as of 9/24/2025. Policy revisions and abuse reporting flowchart completed by 9/24/2025. Audits and monitoring began 9/24/2025 and will continue ongoing. Sustainability will be measured monthly in the QAPI meeting by the QAAC and if any changes are needed within the system, it will be performed immediately. Review of the IJ monitoring for the facility's plan of removal reflected the following: Record review of CNA M employee termination form dated 07/07/2025 indicated CNA M was terminated for violation of company policy and a substantiated abuse allegation. Record review of ST R personnel file the disciplinary action form indicated ST R was suspended from 07/03/2025 to 07/07/2025 for failure to report abuse allegation timely and was reeducated on abuse, neglect and reporting process prior to her returning to duty. Record review of in-service dated 09/24/2025 completed by VP of Clinical Reimbursement, [NAME] President of operations and Corporate Nurse indicated the Administrator and Director of Nursing was trained on abuse, neglect, including types of abuse with examples, steps to prevent abuse (screening, training, prevention, identification, investigation, protection and reporting/response), reportable allegations and abuse allegation reporting time frames. Record review of in-services dated 09/24/2025 completed by the DON, indicated staff were trained on abuse and neglect recognition, types, reporting, examples, reporting abuse allegations immediately, flow chart on reportable allegations, resident to resident altercation prevention, protocol following abuse allegations, caring for residents with aggressive behaviors, supervision, and monitoring. Interviews conducted on 09/25/2025 from 12:00 p.m. through 5:30 p.m. representing staff from various shifts (6 a.m.-2p.m., 2p.m.-10p.m., and 10p.m.-6a.m.) and departments included LVN A, RN B, LVN C, MA G, AD H, HSK J, CNA K, CNA L, LVN S, ST R, CNA V, CNA W, LVN X, LVN AA, CNA BB, CNA CC, CNA DD, CNA EE, LVN FF, CNA GG, CNA HH, CNA II, MA JJ, CNA KK, LVN LL, CNA MM, CNA NN, MT OO, PTA PP, DOR, HSK QQ, FT RR, DD, DA SS, DA TT, DA UU, COOK VV, COOK WW, ADON, Housekeeping Supervisor, and Maintenance Director all said they were in-serviced on 09/24/2025 or prior to their shift on 09/25/2025 and then given quiz to complete to verify their knowledge. All were able to state that their abuse coordinator was the Administrator, if he were not available, they were to notify the DON. They were all able to give examples of physical, verbal, and emotional abuse. They all expressed the importance of reporting alleged abuse immediately when they first saw or heard it. All knew location of abuse reporting flow sheet to use for guide for reportable events. All knew where the corporate compliance and state hotline number was posted and knew when to contact if needed. During interviews on 09/25/2025 from 3:55 p.m.- 4:20 p.m. with 8 (including Resident #2 and Resident #7) alert and oriented residents indicated they recently had communication with management regarding their satisfaction with living at the facility and they had no concerns about their safety, about the staff who provided their daily care, or the management at the facility. During observation on 09/25/2025 from 12:00 p.m. through 5:30 p.m. observed abuse reporting flowchart posted in nurse stations, break rooms, and med rooms. During an interview on 09/25/2025 at 5:00 p.m., the DON said she was given one-on-one in-service with the corporate nurse, VP of operations, and VP of Clinical Reimbursement regarding reporting alleged abuse allegations to the abuse coordinator immediately (if abuse coordinator was not available or was unreachable, then staff would report to her), the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and she was to begin investigating alleged allegations immediately if delegated by the abuse coordinator to do so. She said if abuse was reported to her in the absence of the abuse coordinator that she would report the alleged allegation to HHSC within 2 hours of the alleged incident. She said the alleged perpetrator would be suspended immediately and would not be able to return to work until approval was granted. During an Interview on 09/25/2025 at 5:10 p.m., the Administrator said he was in-serviced one-on-one with the corporate nurse, VP of operations, and VP of Clinical Reimbursement regarding the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and that he was to begin investigating alleged allegations immediately and if he was not available, she was to delegate investigation responsibilities to the DON and/or management staff. She said the alleged perpetrator would be suspended immediately and would not be able to return to work until approval was granted. The Administrator said 95% of the active employees had been in-serviced and the remaining employees would be in-serviced before the start of their next shift. The Administrator said all new hires would receive training on abuse, neglect, and timely reporting prior to providing any resident care. The Administrator was informed that the Immediate Jeopardy was removed on 09/25/2025 at 5:33 p.m. The facility remained out of compliance at a severity level of potential for more than minimal harm, that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to ensure residents the right to be free from abuse for 2 of 15 residents (Residents #1 and Resident #2) reviewed for abuse. The facility failed to ensure Resident #1 and Resident #2 were free from sexual abuse. On 6/15/2024 at 2:03 p.m., Resident #1 provided oral sex to Resident #2 in the dining room of the facility. The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 06/15/2024 and ended on 10/07/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of Resident #1's face sheet dated 10/24/2024 indicated Resident #1 was [AGE] years old male, initially admitted to facility on 06/17/2022 and readmitted to facility on 05/06/2024. His diagnoses included moderate intellectual disabilities (chronic condition that affects a person's ability to think and understand), schizoaffective disorder depressive type (mental illness that involves symptoms of both schizophrenia and depression), dysphagia (difficulty swallowing), dysarthria (a motor speech disorder that makes it difficult to speak clearly due to issues with the muscles used for speech), anarthria (a speech disorder that results from a severe motor impairment and causes a complete or partial loss of speech) and cognitive communication deficit (a difficulty with communication caused by disruption to cognition, or brain processes like attention, memory, and problem solving). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was rarely/never able to make himself understood and usually understands others. He had a BIMS of 03 (severely impaired cognitively). He exhibited no behaviors over the 7 days look back period. He required supervision or moderate assistance for most ADLS. He was frequently incontinent of bladder and bowel. Record review of Resident #1's care plan with a revision dated 06/17/2024 indicated Resident #1 had inappropriate sexual behaviors and was at risk for further episodes and injury AEB a diagnosis of intellectual disability. Interventions included to firmly approach resident that behaviors are not acceptable, administer medications as ordered, inform direct caregivers on methods to assist them in handling resident's inappropriate sexual behaviors while providing care, provide diversional activities, psych services as needed, and redirect during episodes of inappropriate sexual behavior and document in the clinical record. Record review of Resident #1's incident report authored by LVN A indicated on 06/15/2024 at 1:55 p.m. Resident #1 was observed by Resident #3 performing oral sex to Resident #2 in the dining room. Record review of Resident #1's progress note authored by LVN B indicated on 06/15/2024 at 2:03 p.m., [Resident #1] was separated from [Resident #2] area and placed [Resident #1] on the secure unit for now for safety and continue the 1-hour monitoring. Notified Abuse Administrator and DON of full incident. Record review of Resident #1's progress note authored by LVN A indicated on 06/15/2024 at 2:25 p.m., [Resident #3] was sitting in the dining room in the back and observed Resident #1 performing oral sex on Resident #2. CNA assisted [Resident #1] back to his room. [Resident #1] was unable to tell what happened due to Dx of moderate intellectual disability. [Resident #1] assess for any injuries, none noted. [Resident #1] started grabbing at his crotch area, no bruising or abnormalities noted from this area. Administrator, DON, ADON, MD notified, resident RP telephoned, no answer at this time, will continue to call. Resident placed on every 1-hour monitoring; vital signs B/P 122/67, pulse 74, respiratory rate 18, temperature 97.2. No c/o pain or discomfort observed. Record review of Resident #1's progress note authored by LVN A indicated on 06/15/2024 at 8:00 p.m., [Resident #1] was resting in bed at this time with eyes closed, no s/s of distress. No c/o pain or discomfort voiced. Resident RP telephoned x 4 attempts, wireless caller is unavailable at this time, will not allow to leave voice message. Record Review of Resident #1's behavior monitoring log indicated he was monitored hourly from 06/15/2024 at 2:00 p.m. to 07/22/2024 at 5:00 a.m. 2. Record review of a face sheet dated 10/24/2024 indicated Resident #2 was [AGE] years old male, initially admitted to facility on 06/17/2022 and readmitted to facility on 05/06/2024. His diagnoses included hemiplegia and hemiparesis following a cerebrovascular disease affecting left non-dominant side (a stroke or other cerebrovascular disease has damaged the right side of the brain, resulting in weakness or paralysis on the left side of the body), morbid (severe) obesity due to excess calories, post-traumatic stress disorder (a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it), Type 2 Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar), depression (mental illness that negatively affects how you feel, the way you think and how you act) and anxiety (persistent and excessive worry that interferes with daily activities). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. He had a BIMS score of 10 (moderately impaired cognitively). She exhibited no behaviors over the 7 days look back period. He required maximum assistance for most ADLS, requiring supervision for eating and oral hygiene. He was frequently incontinent of bladder and always incontinent of bowel. Record review of Resident #2's care plan with a revision dated 06/17/2024 indicated Resident #2 had inappropriate sexual behaviors and was at risk for further episodes and injury AEB, he allowed an intellectual challenged resident to perform oral sex on him in the dining room and stated the resident was an able body. Interventions included discharge planning (resident on parole), to firmly approach resident that behaviors were not acceptable, administer medications as ordered, inform direct caregivers on methods to assist them in handling resident's inappropriate sexual behaviors while providing care, provide diversional activities, psych services as needed, and redirect during episodes of inappropriate sexual behavior and document in the clinical record. Record review of Resident #2's incident report authored by LVN A indicated on 06/15/2024 at 1:55 p.m. Resident #3 observed Resident #1 performing oral sex to Resident #2 in the dining room. Incident description: Resident #2 stated I did not tell him to do it he just rolled up to me in his wheelchair and started performing sex on me. Resident #2 stated to CN and ADON, that Resident #1 (Dx: moderate intellectual disability) was an able body to suck my D***(penis). Resident #2 stated that he was going to call the police after this CN questioned him about the incident. Resident #2 was asked by the ADON why he did not back up and separate himself from the other resident because he had a power wheelchair, and he could remove himself from the situation. Resident #2 stated that the other resident was an able body. Record review of Resident #2's progress note authored by LVN A indicated on 06/15/2024 at 1:55 p.m., [Resident #3] reported that while she was sitting in the dining room in the back, she observed [Resident #1] performing oral sex on [Resident #2]. [Resident #2] stated that [Resident #1] asked the resident if it was good to him. CN interviewed the resident. [Resident #2] stated I did not tell him to do it he just rolled up to me in his w/c and started performing sex on me. [Resident #2] stated to CN and ADON, that [Resident #1] was an able body to suck my d***(penis), [Resident #2] stated that he was going to call the police after this CN questioned him about the incident. The administrator, DON, ADON, MD and local police were notified of the incident. Local police officer here, statement taken from [Resident #3] and [Resident #2]. Police Officer exit the building, case number given to ADON and administrator. RP notified (resident RP stated that she is not the resident RP the state of Texas is due to the resident being on parole). [Resident #2] remains up in motorized w/c going in and out of other resident's room. [Resident #2] was asked to go to his room, resident attempted to argue with staff. [Resident #2] stated f*** all of you, you have to do a lot of paperwork to get me out of here. You guys allowed this shit to happen. Record review of Resident #2's progress note authored by LVN B indicated on 06/15/2024 at 2:03 p.m., This ADON was called to facility to help with incident between two residents, when entering the facility and reporting to Nurses station, seen local Police Department officer there and getting statements from residents. [Resident #3] and [Resident #2] were in electric wheelchairs sitting there listening to conversations going on, I then asked both residents if I could speak to staff and officer to find out information of incident. [Resident #3] stated ok and moved away as asked, [Resident #2] remained for a while, and stated he would find out what was happening, then asked staff to take Resident #1 to separate him from area and place him on unit for now for safety and continue the 1-hour monitoring. Notified Abuse Administrator and DON of full incident. Record review of Resident #2's progress note authored by LVN B indicated on 06/15/2024 at 2:30 p.m., This nurse continued conversation with local police officer and was told that he will have to contact Special Victims and put this incident in their hands and someone would contact us to investigate further, he gave a paper with names of residents with case number of #2024-011832. He believed [Resident #2] was the one who initiated the incident but could not arrest him because of [Resident #1] had a Dx of Intellectual disabilities and he was unable to give a detailed description of incident, so it was being transferred to the proper unit and detective. [Resident#2] continues to come up to nurse station to listen what is being said and arguing with staff, after police left, I asked Resident #2 to go to his room so I could speak with staff, He then stated, call police or whatever, ya'll allowed this shit to happen. Record review of Resident #2's progress note authored by LVN B indicated on 06/15/2024 at 3:20 p.m., I spoke with Medical Director related to incident and he felt the fact Resident #2 was on parole and posed a threat to other residents that we needed to discharge resident immediately, The police officer stated he could not just take him without proper investigation and charges, also if needed we could also send out Resident #1 if needed if resident started to get upset or seemed to be traumatized from the incident. Record review of Resident #2's progress note authored by LVN B indicated on 06/15/2024 at 3:38 p.m., Resident #2 is aware we, both MD and facility are discussing immediate discharge and speaking to family on phone after police interviews and statements given. Resident #2 stating I won't be going anywhere soon to someone on the phone, and they have no idea how much paperwork they will have to do, in front of staff and residents, resident continues to cuss and become belligerent with staff. Record review of Resident #2's progress note authored by LVN B indicated on 06/15/2024 at 4:25 p.m., This nurse continues to move forward after family of Resident #2 stated they are not his RP and not responsible for him in any way, he is responsibility of the state of Texas, attempted to contact parole board as advised by family, Contacted local police department, that gave me a number to [local] Parole Board and spoke with representative who looked up residents name and stated she would have Resident #2's assigned parole officer to call back. Record review of Resident #2's progress note authored by LVN B indicated on 06/15/2024 at 4:30 p.m., This nurse received call back from assigned parole officer, who was trying to find out information to move forward with discharge and awaiting decision and investigation from local police department, he then asked for case number and stated he would see what he could do as soon as able. Record review of Resident #2's psychiatric evaluation authored by NP AA indicated on 06/25/2024, assessment details, Resident #2 was asked about incident that occurred on 06/15/2024 in dining hall with other resident, as per patients own words I was sitting in the dining room waiting for coffee and (Resident #1) came on my left side which is my blind side, he pulled up front of me, pulls my pants down and put his face in my crotch, he started giving me oral. I pushed him off and was looking to my right for nursing staff, I turned around and he jumped back on it. Treatment plan: utilize behavioral interventions to manage episodical behaviors, redirect as needed and provide support and encouragement to increase positive interactions and socialization, and follow up in 4 weeks or as needed. Record Review of Resident #2's behavior monitoring log indicated he was monitored hourly from 06/15/2024 at 2:00 p.m. to 07/23/2024 at 5:00 a.m. Record review of Provider Investigation report dated 06/15/2024 indicated Description of allegation: Resident #3 observed non-verbal Resident #1, alert x 1, performing oral sex to Resident #2, alert x 4, in the dining room. Assessments: Resident #1 was assessed for injuries with none noted. Provider Response: Resident #1 was immediately move to his room, assessed for injuries, none noted, Administrator, DON, ADON, Physician, and Responsible Party called. Resident #1 placed on Q 1 hour monitoring. After several attempts to get Resident #2 from the area to prevent further abuse, he complied and asked to go lay in his bed. Investigation Summary: Resident #2 was observed pulling Resident #1 head to his genitals and Resident #1 performed oral sex in the dining room. Resident #3, that observed the incident, reported it to the nurses. Resident #2 alert x 4 ambulates in a motorized wheelchair stated to the nurse He was an able body to suck by d k(penis) I did not tell him to do it, he just rolled up to me in his wheelchair and started performing sex on me. Resident #1 is alert x 1 ambulates in wheelchair and is nonverbal with intellectual disabilities. Parties notified: Physician, Administrator, Responsible Parties, DON, ombudsman, and ADON. Facility investigation finding confirmed. Provider action taken post-investigation: Local Police Department was called by Resident #2, referred ADON to contact special victims. Resident #2 is on parole, was issued an Immediate discharge, [NAME] Parole Board staff is assisting with discharges. Resident #2 was seen by LCSW with Psychological Services on 6-16-24. Resident #2 was monitoring every hour until discharged from facility. Resident #1 placed on every 1-hour monitoring, notified local LIDDA. Resident #1 with no behaviors noted, continue to call Responsible Party call goes to voicemail. During an observation and attempted interview on 10/24/2024 at 9:40 a.m., Resident #1 was sitting in his wheelchair in the hallway of the secure unit. He was appropriately dressed and well-groomed. He was unable to answer questions about the incident and just continued to reach out to touch or shake hands or hand/give a teddy bear. Resident #1 non-verbal. No indicators of abuse, neglect or distress observed. During an observation and interview on 10/24/2024 at 10:00 a.m., Resident #2 was lying in his bed in his room. He was lying in bed with no shirt on and well-groomed. He said that he gets warm easily, so he did not wear a shirt while in his room. Resident #2 was asked about incident that occurred on 06/15/2024 in dining hall with the other resident, as per patients own words I was sitting in the dining room waiting for coffee and (Resident #1) came on my left side, which is my blind side, he pulled up front of me, pulls my pants down and pulls out by penis and started giving me oral sex. I pushed him off and was looking to my right for nursing staff, I turned around and he jumped back on it. He said it lasted maybe 40 seconds, and I moved away as soon as I could. I didn't make him do that, called the police because he wanted it to be on record. Resident #2 said police officer visited with him and took his statement and report filed. Attempted to contact Resident #1's RP on 10/24/2024 at 5:30 p.m. and 10/25/2024 at 11:00 a.m. with no answer and unable to leave voice mail. During an interview on 10/23/2024 at 4:00 p.m., LVN A said that Resident #3 had reported to her that she observed Resident #1 giving oral sex to Resident #2 in the facility dining room. LVN A said that she went to the dining area but did not observe the sexual act. LVN A said she had CNA take Resident #1 to his room and she went to his room and did a head-to-toe assessment with no injuries noted. LVN A said she notified the MD, ADON, and the administrator and attempted to notify the RP but did not contact her. LVN A said that Resident #1 was placed on every hour monitoring and did not exhibit any s/s of distress from the incident during her shift. LVN A said that Resident #1 was placed in the secure unit briefly after the incident for his safety because Resident #2 was up in his electric wheelchair and refusing to go to his room and lie down, so placed Resident #1 in the secure unit until Resident #2 was placed in bed in his room. Attempted to call LVN B on 10/24/2024 @ 5:10 p.m. and 6:10 p.m. via telephone for interview, unsuccessful with no answer or returned call. Record review of facility census indicated that Resident #3, no longer resided at facility. An attempt was made to call Resident #3 via telephone on 10/24/2024 at 5:15 p.m. and 6:15 p.m The attempts were unsuccessful with no answered or returned phone calls. During an interview on 10/24/2024 at 3:50 p.m., SW said that she was new to the facility but was aware of the incident between Resident #1 and Resident #2. She said that she had reviewed Resident #2's file and ongoing communications with probation officer and continues to work with other facilities for possible transfer or discharge of Resident #2 to another facility. SW said that Resident #1 and Resident #2 were provided behavioral support after the incident. During an interview on 10/24/2024 at 4:00 p.m., the ADON said she was not the acting ADON during the time of the incident between Resident #1 and Resident #2. She said she was aware that would be considered sexual abuse. The ADON said she notifies the Administrator/Abuse Prevention Coordinator immediately by phone/text of any allegation of abuse. The ADON said new protocol for abuse incidents was that staff should immediately remove residents from the situation and stay with the aggressor one-on-one until further instruction from the Abuse Coordinator or MD. ADON said Resident #1 resides in the secure unit and has no contact or communication with Resident #2. During an interview on 10/24/2024 at 4:55 p.m., the Administrator said she was not the active administrator during the incident between Resident #1 and Resident #2, but she had recently (10/05/2024 and 10/06/2024) conducted in-services with all staff addressing the facility abuse/neglect policy and initiating one-on-one monitoring with the aggressor until they were given further instructions on monitoring. She had addressed the different types of abuse and staff had passed a written test. She said she instructed staff on the documentation in behavior monitoring logs. She in-serviced staff on the facility's behavioral management policy which included resident abuse. She said staff were required to pass behavioral management test. She said not keeping the residents free from abuse could place them at risk of abuse, physical harm, mental anguish, and emotional distress. Record review of the undated facility's Abuse and Neglect policy indicated .It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. III. Prevention: Have procedures to provide residents, families, and staff information on how and to whom they may report concerns, incidents and grievances without fear of retribution; and provide feedback regarding the concerns that have been expressed. Identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur. Establish a safe environment that supports consensual sexual relationship. Develop and implement policy on abuse, neglect, theft, exploitation, and misappropriation of property. Deployment of sufficient and trained staff to deal with behaviors in the units. Identification, assessment, care planning for intervention, and monitoring of residents with needs and behaviors that might lead to conflicts or neglect. The supervisions of staff to identify inappropriate behaviors .ensuring health and safety of residents .VI. Protect residents from physical and psychosocial harm during investigations. 1. If the allegation of abuse involves 2 or more residents, they will all be immediately separated for the protection of all residents involved and those potentially affected by the abuse. 2. Affected residents will be assessed for injury. 3. Attending physician will be notified. a. This includes but not limited to full assessment of physical and psychosocial well-being; sending resident to hospital if needed; depending on circumstance, keep resident on 1:1, assign a female/male depending on the accusation/allegation. Record review of facility incident/accident reports indicated no other incidents of inappropriate sexual behaviors. Record review of quiz results, dated 10/05/24 and 10/06/24, indicated all staff passed the quiz regarding abuse, neglect, reporting, behavioral monitoring and one-on-one monitoring. Record review of a list of all facility staff used for tracking the required in-service training on abuse/neglect, behavioral monitoring, and behavioral management indicated all facility staff had received the in-service training in person or by phone on 10/05/2024 or 10/06/2024. During interviews on 10/24/24 from 3:30 p.m. though 5:30 p.m. and 10/25/2024 from 8:00 a.m. though 10:30 a.m., 4 LVNs (LVN A, LVN C, LVN D, LVN E ), 2 MAs ( MA P and MA Q), 10 CNA's (CNA F, CNA G, CNA H, CNA I, CNA J, and CNA K), 1 Activity Director, 1 Social Worker, 1 Dietary staff (Dietary Manager S), 3 Housekeeping staff (Housekeeper T, U, V) and 1 Maintenance (Maintenance W) were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the Administrator and were able to give examples of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/or identified, such as immediately removing residents from the situation and stay with the aggressor one-on-one until further instruction from the Abuse Coordinator. They verbalized proper documentation of behavior monitoring logs. The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 06/15/2024 and ended on 10/07/2024. The facility had corrected the noncompliance before the survey began.

36214 Based on observation, interview, and record review, the facility failed to ensure residents the right to be free from abuse for 2 of 6 residents (Residents #Unnamed & Resident #4) reviewed for abuse. 1. On 08/02/24 Resident #1 was grabbing Resident #Unnamed breasts. 2. On 08/25/24 Resident #1 touched Resident #4's breast. On 10/05/24 at 4:40 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/06/24, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of the Plan of Removal. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of a face sheet dated 09/23/24 indicated Resident #1 was [AGE] years old, initially admitted to facility on 03/07/24 and readmitted to facility on 09/09/24. His diagnoses included dementia (loss of cognitive functioning), delusional disorder (a mental health condition that causes unshakable beliefs in something that's untrue), hypertension (condition in which the force of the blood against the artery walls is too high), dysphagia (difficulty swallowing) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #1's care plan with revision dated 04/24/24 indicated Resident #1 had inappropriate sexual behaviors; resident seeks to satisfy his sexual desires. Interventions included to firmly approach resident that behaviors are not acceptable and document conversations and actions of resident; inform direct caregivers on methods to assist them in handling resident behaviors while providing care; monitor whereabouts of resident and keep distance from others; provide diversional activities and redirect when behaviors happen and document. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #1 was usually able to make himself understood and usually understands others. He had a BIMS of 08 (moderately impaired cognitively). He exhibited no behaviors over the 7 days look back period. He required supervision or moderate assistance for most ADLS. He was frequently incontinent of bladder and bowel. Record review of Resident #1's progress note authored by previous DON R indicated on 08/02/24 at 8:42 a.m., Resident #1 was in the dining room this morning grabbing other resident's breast when nurse tried to redirect him, he stated let me see your pussy. Nurse informed him that this kind of behavior would not be accepted. Nurse phoned MD and made him aware of situation. Received one time order for lorazepam 1 milligram IM for agitation. Record review of an unsigned 24-hour report indicated: 08/02/24 08:42 a.m. - Behavior Note Resident #1 was in the dining room this morning grabbing other resident breasts. When SN tried to redirect him, he stated, Let me see your pussy. SN informed him that this kind of behavior would not be accepted. SN phoned MD and made him aware of the situation. Received on time order for Lorazepam 1 mg IM for agitation. 08/02/24 10:21 a.m. - Social Services SSD sent referral over to behavioral unit at local hospital per DON who said to refer Resident #1 due to behavior displayed. Spoke with rep who said that he would need to be transported to the ER to be assessed. SSD said she would speak to the ADON/DON on how to proceed. 08/02/24 11:29 a.m. - Behavior Note Resident has been extremely inappropriate to staff and other residents sexually. Speaking graphically lewd and grabbing resident's breasts, then laughing and leering. Unable to redirect. DON notified. 08/02/24 12:32 a.m. - Nurses Note Resident #1 sent to hospital ER for psych evaluation due to inappropriate sexual behavior. Record Review of Resident #1's behavior monitoring log indicated on 08/02/24 Resident #1 was monitored hourly from 9:00 a.m. until 12:30 p.m. Record review of Resident #1's progress note authored by LVN Q on 08/05/24 at 12:55 p.m., indicated the behavioral hospital called to inform facility that Resident #1 did not meet criteria for extended stay and the unit was full. Resident #1 would be transferred back to the facility (on 08/05/24). Record review of Resident #1's psychiatric assessment note dated 08/05/24 and completed by NP AA indicated Resident #1 was seen for a hospital follow up visit for exhibiting anxiety symptoms and hypersexual behaviors toward female peers and staff. Psych treatment plan included to start Resident #1 on Rivastigmine (used for the treatment of mild to moderate Alzheimer's disease) 1.5 mg daily for inappropriate sexual behaviors in dementia, utilize behavioral interventions to manage episodic behaviors, redirect as needed and provide support and encouragement to increase positive interactions and socialization, and follow up in 4 weeks or as needed. Record review of Resident #1's progress note authored by LVN Q on 08/07/24 at 7:10 a.m. indicated Resident #1 continued to speak sexually inappropriately to staff. Resident #1 appeared exhausted, and shower was given to calm resident. Record review of Resident #1's behavior monitoring log did not indicate Resident #1 had any increased monitoring after discharge from behavioral hospital on 08/05/24. During an observation and interview on 09/30/24 at 11:45 a.m., Resident #1 was sitting up in wheelchair in secure unit dining room. He said he did not recall the incident involving him inappropriately touching other residents that happened on 08/02/24. Resident #1 said that he knew that he was not supposed to touch or hit other residents or staff. Resident #1 was observed trying to stand up without assistance and staff intervened and redirect him by providing activities. Resident #1 was one of 6 residents in the dining room. During an interview on 09/30/24 at 1:00 p.m., the Administrator said there was no incident report for Resident #1's sexually inappropriate behaviors on 08/02/24. During an interview on 09/30/24 at 2:48 p.m., LVN Q said she was the CN on duty on 08/02/24 and vaguely recalled the incident with Resident #1 touching another female resident's breast. She said she recalled that the incident was in the dining room of the secure unit, and he touched the female's breast and was laughing and leering. He was unable to be redirected, and when removed from the area by staff he was talking sexually to staff and grabbing at their breast. She said that she notified the DON and MD. She said Resident #1 was monitored until he was transferred to a local hospital for evaluation for placement into their behavioral unit. She said she did not recall the female's name that he touched inappropriately. She said that she was in the unit covering for the CNA when the incident occurred, and it was not witnessed by other staff. During an interview on 09/30/24 at 3:30 p.m., the previous DON R said she was the active DON at the facility on 08/02/24. She recalled the incident with Resident #1 touching another female resident's breast. She said she was called to the secure unit that morning after breakfast and the CN reported that Resident #1 had touched another female resident's breast and was laughing and leering and was unable to be redirected and when removed from the area by staff he was talking sexually to staff and grabbing at their breast. She said she told the CN to keep Resident #1 on one-to-one monitoring and that she requested the SW to contact a local behavioral hospital for a transfer due to the behavior. She said that she notified all department heads (including the Administrator) during the 9:00 am morning meeting that day. She said Resident #1 was monitored until he was transferred to a local hospital for evaluation for placement into their behavioral unit. She said she did not recall the female resident's name that Resident #1 touched inappropriately. During an interview on 09/30/24 at 3:55 p.m., previous the Administrator S she said she was the active Administrator on 08/02/24. She said she was not notified of Resident #1 touching another female resident's breast on 08/02/24. She said that was considered sexual abuse. During an interview on 09/30/24 at 4:00 p.m., the ADON said she did not recall the incident with Resident #1 touching another female resident's breast on 08/02/24. She said she was aware that would be considered sexual abuse. The ADON said she notifies the Administrator/Abuse Prevention Coordinator immediately by phone/text of any allegation of abuse. The ADON said residents with behaviors were monitored and incidents were reported to the MD/NP. If MD ordered, resident would be transferred behavioral hospital for evaluation and treatment. During an interview on 10/05/24 at 9:41 a.m., CNA E said she had never observed Resident #1 touch any residents or staff inappropriately. She said she was never told he needed to be monitored closely due to inappropriate sexual touching. She said she knew he talked inappropriately to staff, and he had said many lewd comments to her. During an interview on 10/05/24 at 9:44 a.m., CNA CC said Resident #1 always talked sexually to staff and he had said some vulgar things to her, but she was never told he had sexually/inappropriately touched another resident. 2. Record review of a face sheet dated 10/05/24 indicated Resident #4 [AGE] years old, initially admitted to the facility 03/13/24 and readmitted on [DATE]. Her diagnosis included dementia (loss of cognitive functioning), cognitive communication deficit (a difficulty with communication caused by disruption to cognition, or brain processes like attention, memory, and Problem solving), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #4 was usually understood and sometimes understands others. She had a BIMS of 08 (moderately impaired cognitively). She exhibited no behaviors over the 7 days look back period. She required moderate assistance for most ADLS. She was always incontinent of bladder and frequently incontinent of bowel. Record review of a care plan last revised 07/19/24 for Resident #4 did not indicate she had been touched inappropriately on 08/25/24. Record review of an incident report dated 08/25/24 at 7:45 a.m. and signed by RN U indicated CNA heard Resident #4 yell, let go of my titty. CNA saw Resident #1 grabbing Resident #4's breast and reported the incident to her. Record review of an incident report dated 08/25/24 at 11:18 a.m. and signed by RN U indicated CNA reported to her that she saw Resident #1 touch a female resident on her breast. Residents were separated. Calls placed to notify ADON, NP, and RN T (previous Abuse Coordinator) and resident's FM UU. Resident #1 was on every 30-minute monitoring. Record review of a behavior monitoring log indicated Resident #1 was monitored hourly from 08/25/24 at 8:00 a.m. to 08/27/24 at 10:00 p.m. There was no documentation of further monitoring. Record review of a progress note dated 08/28/24 at 9:22 a.m. authored by previous MDS Coordinator DD indicated call placed to responsible party of Resident #1 to inform that Resident #1 has been having changes in behavior, both inappropriate sexual behaviors and aggressive behavior. Resident has been accepted to a behavioral hospital. RP said OK, thank you. Record review of a progress note dated 08/28/24 at 10:33 a.m. authored by the ADON indicated Resident #1 left facility with transportation company in route to behavioral hospital. During an interview on 09/25/24 at 10:21 a.m. RN T said she was made aware of the incident between Resident #1 and Resident #4. She said staff reported to her (the acting abuse coordinator) Resident #1 and Resident #4 were sitting at a dining table on the secure unit. Staff reported Resident #4 said Resident #1 grabbed her. Resident #1 denied he grabbed Resident #4's breast. She said both residents had low BIMS scores and there was no willful intent. During an interview on 09/25/24 at 12:15 p.m., CNA BB said she was getting all the residents into the dining room for the breakfast meal. She said it looked like Resident #1 was touching Resident #4's breast and then he reached for the coloring book and crayons that was on the dining table. She said she told Resident #1 he did not need to be so close to the ladies and he moved away. She said she advised RN U of the incident. She said RN U called the abuse coordinator. She said Resident #4 did not say anything. She said Resident #1 said he did not touch Resident #4's breast. He said he was reaching for the crayons. During an interview on 9/27/2024 at 4:00 pm, RN U said that on 8/25/2024 a CNA reported to her that Resident #1 touched a female resident on her breast. RN U said Resident #1 was separated from the female resident, assessed and behavioral monitoring initiated. RN U said she reported the incident to the ADON, NP/MD, AC (RN T) and RP. RN U said that Resident #1 was placed on behavioral monitoring for the incident until the AC (RN T) completed an abuse investigation. RN U said that there were 2 CNAs working the secure unit on 8/25/2024 to provide behavioral monitoring for the incident until the AC (RN T) completed an abuse investigation. RN U said if residents had behaviors that facility staff notify the NP/MD and place the residents on behavioral monitoring, depending on the MD orders and/or severity of the behavior's resident may be sent out to behavioral hospital for evaluation and treatment. She said Resident #1 was monitored q15 minutes. During an observation and interview on 10/05/24 at 9:39 a.m., Resident #4 was sitting in her wheelchair in the dining room of the secure unit. She was appropriately dressed and well-groomed. She was unable to answer questions about the incident and just repeated words spoken to her. During an interview on 10/05/24 at 3:55 p.m., the Administrator said that she was not the active Administrator/Abuse Coordinator at the time of the incidents with Resident #1 touching another female resident's breast on 08/02/24 or on 08/25/24 when Resident #1 touched Resident #4's breast. She said her expectation for incidents involving resident to resident abuse was for the residents to be separated and the aggressor to be placed on one-on-one monitoring for the protection of other residents. She said her expectation was care plans be updated when incidents occur, but the current MDS nurse worked remotely and might not have been aware of the incidents. She said the possible negative outcome of not protecting the residents could be physical, emotional, or psychological harm of the residents. Record review of the undated facility's Abuse and Neglect policy indicated .It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. III. Prevention: Have procedures to: provide residents, families, and staff information on how and to whom they may report concerns, incidents and grievances without fear of retribution; and provide feedback regarding the concerns that have been expressed. Identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur. Establish a safe environment that supports consensual sexual relationship. Develop and implement policy on abuse, neglect, theft, exploitation, and misappropriation of property. Deployment of sufficient and trained staff to deal with behaviors in the units. Identification, assessment, care planning for intervention, and monitoring of residents with needs and behaviors that might lead to conflicts or neglect. The supervisions of staff to identify inappropriate behaviors .ensuring health and safety of residents .VI. Protect residents from physical and psychosocial harm during investigations. 1. If the allegation of abuse involves 2 or more residents, they will all be immediately separated for the protection of all residents involved and those potentially affected by the abuse. 2. Affected residents will be assessed for injury. 3. Attending physician will be notified. a. This includes but not limited to full assessment of physical and psychosocial well-being; sending resident to hospital if needed; depending on circumstance, keep resident on 1:1, assign a female/male depending on the accusation/allegation. This was determined to be an Immediate Jeopardy (IJ) on 10/05/24 at 4:40 p.m. The Administrator was notified. The Administrator was provided the IJ template on 10/05/24 at 4:45 p.m. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 10/06/24 at 1:50 p.m. and reflected the following: Action: On 10/05/24 R1 was immediately placed on q 15-minute checks for close monitoring for further behaviors. R1 will remain on q 15-minute checks until IDT team meets in 30 days and reevaluate his behaviors for medical adjustment and determine if R1 will remain on q 15-minute checks or can be discontinued. If Res #1 has additional behaviors, he will be placed one-on-one until psychiatric services can reevaluate his behaviors. Res #1 was placed on q 15 minutes checks due to the recurrent behaviors that require closer monitoring. Charge nurse/nurse managers Immediately assessed R2 and the rest of the residents in the secure unit for possible mental, physical, or sexual abuse, no additional mental health needs were identified, nor any suspected physical abuse found at this time. 0 out of 10 residents were affected. Administrator/abuse coordinator Immediately reeducated all staff 100% completion on Abuse & Neglect policy for types of abuse (physical, sexual, mental, verbal, neglect, exploitation, and misappropriation) through verbal in-service and written test. Staff were also reeducated for the identification, and intervention in a situation in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur. This education included protecting and/or removing the resident from the situation, as well as who the abuse coordinator is, when to report, and how to report abuse. Staff were reeducated to stay with the aggressor one-on-one until further instruction from the abuse coordinator and/or until the evaluation or further intervention. on 10/05/24 the Administrator, reeducated 100% of staff on behavioral management policy which included resident to resident abuse in regard to residents exhibiting sexual behaviors towards other and steps to do and approach the situation. Reeducation was provided for the staff with instructions for proper documentation for the behavior monitoring log through verbal in-service with monitoring log attached. Staff were reeducated through verbal in-servicing, tests, and questionnaires. On 10/05/24 MDS nurse immediately reviewed and updated care plan to reflect sexually inappropriate behaviors. The MDS nurse will review all incident reports related to sexual behaviors to make sure interventions were in place, for the floor staff to be able to see in electronic health record (EHC). Administrator/and or designee will reeducate floor staff to review Kardex in PCC (EHC) for updated interventions for each resident. On 10/06/24 at 11:48 a.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During interviews conducted on 10/06/24 from 11:05 a.m. though 3:48 p.m. included LVN EE 6:00 a.m. - 6:00 p.m. weekends, LVN FF (6:00 a.m. to 6:00 p.m.) weekends, LVN B (6:00 a.m. 2:00 p.m.), LVN GG (2:00 p.m. to 10:00 p.m.), LVN HH (10:00 p.m. to 6:00 a.m.), LVN X (10:00 p.m. to 6:00 a.m.), MA J (6:00 a.m. to 2:00 p.m & 2:00 p.m. to 10:00 p.m., CNA CC (6:00 a.m. to 2:00 p.m.), CNA E (6:00 a.m. to 2:00 p.m.), CNA JJ (6:00 a.m. to 2:00 p.m.), CNA KK (6:00 a.m. to 2:00 p.m.), CNA LL (6:00 a.m. to 2:00 p.m.), CNA D (2:00 p.m. to 10:00 p.m.), CNA MM (2:00 p.m. to 10:00 p.m.), CNA NN (10:00 p.m. to 6:00 a.m.), and CNA OO (10:00 p.m. to 6:00 a.m.), CNA PP (10:00 p.m. to 6:00 a.m.), Dietary Aide QQ, Housekeeper RR, Occupational Therapist SS, Staffing LVN TT and ADON who worked all shifts. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the Administrator and were able to give examples of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/or identified, such as immediately removing residents from the situation and stay with the aggressor one-on one until further instruction from the Abuse Coordinator. They verbalized proper documentation of behavior monitoring logs. CNA CC and CNA E said they were now aware of Resident #1's sexual behaviors and the resident was to be monitored q15 minutes. They said they documented every 15 minutes on Resident #1's behavior monitoring log. CNA CC and CNA E said they were in-serviced on abuse/neglect and gave examples of physical, verbal, and sexual abuse. They said the Administrator was the Abuse Coordinator and they would immediately report any abuse/neglect allegations to the Administrator. CNA CC and CNA E gave examples of immediate interventions they would take when an allegation or made incuding removing residents from the situation and staying with the aggressor one on one until the Administrator was notifed and gave further instruction. During an interview on 10/06/24 at 3:55 p.m., the Administrator said she had conducted in-services with all staff addressing the facility abuse/neglect policy and initiating one-on-one monitoring with the aggressor until they were given further instructions on monitoring. She had addressed the different types of abuse and staff had passed a written test. She said she instructed staff on documentation in behavior monitoring logs. She in-serviced staff on the facility's behavioral management policy which included resident abuse. She said staff were required to pass behavioral management test. She said Resident #1's care plan had been updated and a q15 minute monitoring was required by staff until the IDT meeting in 30 days to re-evaluate his behaviors. During an observation and interview on 10/06/24 at 1:15 p.m., Resident #1 was in the TV room with CNA E with no sexual behaviors noted. CNA E said she was assigned to monitor Resident #1 because he was being monitored q15 minutes for sexual behaviors and she was observed documenting the checks on his behavioral monitoring log. Record review of behavioral monitoring logs for Resident #1 indicated he was being monitored by staff every 15 minutes beginning on 10/05/24 at 6:00 p.m. to monitor for sexually inappropriate behaviors. Record review of a check off list of secured unit residents indicated all residents on the secure unit were assessed by charge nurses and the ADON. Record review of nursing assessments completed by the ADON and charge nurses for Resident #4 and all other secure unit residents indicated all residents were assessed for physical and psychosocial changes on 10/05/24. There was no evidence of sexual abuse noted on the assessments. Record review of Resident #1's care plan indicated it was updated on 10/05/24 and included he exhibiting unwanted sexual behaviors with interventions of referral to psychiatric services and increased monitoring for behaviors and changes in mental status. Record review of Resident #4's care plan indicated it was updated on 10/05/24. Record review of facility incident/accident reports indicated no other incidents of inappropriate sexual behaviors. Record review of quiz results, dated 10/05/24 and 10/06/24, indicated all staff passed the quiz regarding abuse, neglect, reporting, and one-on-one monitoring. Record review of a list of all facility staff used for tracking the required in-service training on abuse/neglect, behavioral monitoring, and behavioral management indicated all facility staff had received the in-service training in person or by phone. The Administrator was informed the IJ was removed on 10/06/24 at 3:58 p.m. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

36214 Based on observation, interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 of 6 residents (Resident #4 and Resident #Unnamed) reviewed for abuse and neglect. 1. The facility failed to implement their written policies and procedures to prevent sexual abuse and potential further sexual abuse by Resident #1 when Resident #1 grabbed Resident #Unnamed's breast. 2. The facility failed to implement their written policies and procedures to prevent sexual abuse and potential further sexual abuse by Resident #1 when Resident #1 touched Resident #4's breast. On 10/05/24 at 4:40 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/06/24, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of the Plan of Removal. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings include: 1. Record review of a face sheet dated 09/23/24 indicated Resident #1 was [AGE] years old, initially admitted to facility on 03/07/24 and readmitted to facility on 09/09/24. His diagnoses included dementia (loss of cognitive functioning), delusional disorder (a mental health condition that causes unshakable beliefs in something that's untrue), hypertension (condition in which the force of the blood against the artery walls is too high), dysphagia (difficulty swallowing) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #1's care plan with revision dated 04/24/24 indicated Resident #1 had inappropriate sexual behaviors; resident seeks to satisfy his sexual desires. Interventions included to firmly approach resident that behaviors are not acceptable and document conversations and actions of resident; inform direct caregivers on methods to assist them in handling resident behaviors while providing care; monitor whereabouts of resident and keep distance from others; provide diversional activities and redirect when behaviors happen and document. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #1 was usually able to make himself understood and usually understands others. He had a BIMS of 08 (moderately impaired cognitively). He exhibited no behaviors over the 7 days look back period. He required supervision or moderate assistance for most ADLS. He was frequently incontinent of bladder and bowel. Record review of Resident #1's progress note authored by previous DON R indicated on 08/02/24 at 8:42 a.m., Resident #1 was in the dining room this morning grabbing other resident's breast when nurse tried to redirect him, he stated let me see your P---. Nurse informed him that this kind of behavior would not be accepted. Nurse phoned MD and made him aware of situation. Received one time order for lorazepam 1 milligram IM for agitation. Record review of an unsigned 24-hour report indicated: 08/02/24 08:42 a.m. - Behavior Note Resident #1 was in the dining room this morning grabbing other resident breasts. When SN tried to redirect him, he stated, Let me see your pussy. SN informed him that this kind of behavior would not be accepted. SN phoned MD and made him aware of the situation. Received on time order for Lorazepam 1 mg IM for agitation. 08/02/24 10:21 a.m. - Social Services SSD sent referral over to behavioral unit at local hospital per DON who said to refer Resident #1 due to behavior displayed. Spoke with rep who said that he would need to be transported to the ER to be assessed. SSD said she would speak to the ADON/DON on how to proceed. 08/02/24 11:29 a.m. - Behavior Note Resident has been extremely inappropriate to staff and other residents sexually. Speaking graphically lewd and grabbing resident's breasts, then laughing and leering. Unable to redirect. DON notified. 08/02/24 12:32 a.m. - Nurses Note Resident #1 sent to hospital ER for psych evaluation due to inappropriate sexual behavior. Record Review of Resident #1's behavior monitoring log indicated on 08/02/24 Resident #1 was monitored hourly from 9:00 a.m. until 12:30 p.m. Record review of Resident #1's progress note authored by LVN Q on 08/05/24 at 12:55 p.m., indicated the behavioral hospital called to inform facility that Resident #1 did not meet criteria for extended stay and the unit was full. Resident #1 would be transferred back to the facility (on 08/05/24). Record review of Resident #1's behavior monitoring log did not indicate Resident #1 had any increased monitoring after discharge from behavioral hospital on 08/05/24. During an observation and interview on 09/30/24 at 11:45 a.m., Resident #1 was sitting up in wheelchair in secure unit dining room. He said he did not recall the incident involving him inappropriately touching other residents that happened on 08/02/24. Resident #1 said that he knew that he was not supposed to touch or hit other residents or staff. Resident #1 was observed trying to stand up without assistance and staff intervened and redirect him by providing activities. Resident #1 was one of 6 residents in the dining room. During an interview on 09/30/24 at 2:48 p.m., LVN Q said she was the CN on duty on 08/02/24 and vaguely recalled the incident with Resident #1 touching another female resident's breast. She said she recalled that the incident was in the dining room of the secure unit, and he touched the female's breast and was laughing and leering. He was unable to be redirected, and when removed from the area by staff he was talking sexually to staff and grabbing at their breast. She said that she notified the DON and MD. She said Resident #1 was monitored until he was transferred to a local hospital for evaluation for placement into their behavioral unit. She said she did not recall the female's name that he touched inappropriately. She said that she was in the unit covering for the CNA when the incident occurred, and it was not witnessed by other staff. During an interview on 09/30/24 at 3:30 p.m., the previous DON R said she was the active DON at the facility on 08/02/24. She recalled the incident with Resident #1 touching another female resident's breast. She said she was called to the secure unit that morning after breakfast and the CN reported that Resident #1 had touched another female resident's breast and was laughing and leering and was unable to be redirected and when removed from the area by staff he was talking sexually to staff and grabbing at their breast. She said she told the CN to keep Resident #1 on one-on-one monitoring and that she requested the SW to contact a local behavioral hospital for a transfer due to the behavior. She said that she notified all department heads (including the Administrator) during the 9:00 am morning meeting that day. She said Resident #1 was monitored until he was transferred to a local hospital for evaluation for placement into their behavioral unit. She said she did not recall the female resident's name that Resident #1 touched inappropriately. During an observation on 10/05/24 at 9:35 a.m., Resident #1 was in his wheelchair alone in the hallway of the secure unit. During an observation and interview on 10/05/24 at 9:41 a.m., CNA E was in the dining room of the secure unit with 5 residents. She said she had never observed Resident #1 touch any residents or staff inappropriately. She said she was never told he needed to be monitored closely due to inappropriate sexual touching. During an observation and interview on 10/05/24 at 9:44 a.m., CNA CC was in the dining room of the secure unit with 5 residents. She said Resident #1 always talked sexually to staff and he had said some vulgar things to her, but she was never told he had sexually/inappropriately touched another resident or to monitor him closely. 2. Record review of a face sheet dated 10/05/24 indicated Resident #4 [AGE] years old, initially admitted to the facility 03/13/24 and readmitted on [DATE]. Her diagnosis included dementia (loss of cognitive functioning), cognitive communication deficit (a difficulty with communication caused by disruption to cognition, or brain processes like attention, memory, and Problem solving), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #4 was usually understood and sometimes understands others. She had a BIMS of 08 (moderately impaired cognitively). She exhibited no behaviors over the 7 days look back period. She required moderate assistance for most ADLS. She was always incontinent of bladder and frequently incontinent of bowel. Record review of a care plan last revised 07/19/24 for Resident #4 did not indicate she had been touched inappropriately on 08/25/24. Record review of an incident report dated 08/25/24 at 7:45 a.m. and signed by RN U indicated CNA heard Resident #4 yell, let go of my titty. CNA saw Resident #1 grabbing Resident #4's breast and reported the incident to her. Record review of an incident report dated 08/25/24 at 11:18 a.m. and signed by RN U indicated CNA reported to her that she saw Resident #1 touch a female resident on her breast. Residents were separated. Calls placed to notify ADON, NP, and RN T (previous Abuse Coordinator) and resident's FM UU. Resident #1 was on every 30-minute monitoring. Record review of a behavior monitoring log indicated Resident #1 was monitored hourly from 08/25/24 at 8:00 a.m. to 08/27/24 at 10:00 p.m. There was no documentation of further monitoring. Record review of a progress note dated 08/28/24 at 9:22 a.m. authored by previous MDS Coordinator DD indicated call placed to responsible party of Resident #1 to inform that resident has been having changes in behavior, both inappropriate sexual behaviors and aggressive behavior. Resident has been accepted to a behavioral hospital. Record review of a Behavior Monitor Post an Incident in-service dated 8/28/24 indicated, Immediately after an incident involving resident with physical, verbal, or sexual aggression, the CN will place the resident on monitoring checks, and fill out the from q 1 hr, q 30 min, q 15 min. Call provider and supervisor to notify them of incident. They will continue monitoring checks until the IDT can review the incident and place further interventions. During an interview on 09/25/24 at 10:21 a.m. RN T said she was made aware of the incident between Resident #1 and Resident #4. She said staff reported to her (the acting abuse coordinator) Resident #1 and Resident #4 were sitting at a dining table on the secure unit. Staff reported Resident #4 said Resident #1 grabbed her. Resident #1 denied he grabbed Resident #4's breast. She said both residents had low BIMS scores and there was no willful intent. During an interview on 09/25/24 at 12:15 p.m., CNA BB said she was getting all the residents into the dining room for the breakfast meal. She said it looked like Resident #1 was touching Resident #4's breast and then he reached for the coloring book and crayons that was on the dining table. She said she told Resident #1 he did not need to be so close to the ladies and he moved away. She said she advised RN U of the incident. She said RN U called the abuse coordinator. She said Resident #4 did not say anything. She said Resident #1 said he did not touch Resident #4's breast. He said he was reaching for the crayons. During an interview on 9/27/2024 at 4:00 pm, RN U said that on 8/25/2024 a CNA reported to her that Resident #1 touched a female resident on her breast. RN U said Resident #1 was separated from the female resident, assessed and behavioral monitoring initiated. RN U said she reported the incident to the ADON, NP/MD, AC (RN T) and RP. RN U said that Resident #1 was placed on behavioral monitoring for the incident until the AC (RN T) completed an abuse investigation. RN U said that there were 2 CNAs working the secure unit on 8/25/2024 to provide behavioral monitoring for Resident #1, but one-on-one monitoring was not initiated. She said Resident #1 was monitored q15 minutes. During an observation and interview on 10/05/24 at 9:39 a.m., Resident #4 was sitting in her wheelchair in the dining room of the secure unit. She was appropriately dressed and well-groomed. She was unable to answer questions about the incident and just repeated words spoken to her. During an interview on 10/05/24 at 3:55 p.m., the Administrator said that she was not the active Administrator/Abuse Coordinator at the time of the incidents with Resident #1 touching another female resident's breast on 08/02/24 or on 08/25/24 when Resident #1 touched Resident #4's breast. She said her expectation for incidents involving resident to resident abuse was for the residents to be separated and the aggressor to be placed on one-on-one monitoring for the protection of other residents. She said the facility policy on abuse and neglect addressed protecting residents from harm during the investigation of the incident and placing the resident on one-on-one monitoring. She said the facility abuse policy was not followed for the incidents involving Resident #1. She said the possible negative outcome of not performing one-on-one monitoring of the resident and protecting the other residents could be physical, emotional, or psychological harm of the residents. She said her expectation was care plans be updated when incidents occur, but the current MDS nurse worked remotely and might not have been aware of the incidents. Record review of the undated facility's Abuse and Neglect policy indicated .It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. III. Prevention: Have procedures to: provide residents, families, and staff information on how and to whom they may report concerns, incidents and grievances without fear of retribution; and provide feedback regarding the concerns that have been expressed. Identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur. Establish a safe environment that supports consensual sexual relationship. Develop and implement policy on abuse, neglect, theft, exploitation, and misappropriation of property. Deployment of sufficient and trained staff to deal with behaviors in the units. Identification, assessment, care planning for intervention, and monitoring of residents with needs and behaviors that might lead to conflicts or neglect. The supervisions of staff to identify inappropriate behaviors .ensuring health and safety of residents .VI. Protect residents from physical and psychosocial harm during investigations. 1. If the allegation of abuse involves 2 or more residents, they will all be immediately separated for the protection of all residents involved and those potentially affected by the abuse. 2. Affected residents will be assessed for injury. 3. Attending physician will be notified. a. This includes but not limited to full assessment of physical and psychosocial well-being; sending resident to hospital if needed; depending on circumstance, keep resident on 1:1, assign a female/male depending on the accusation/allegation. This was determined to be an Immediate Jeopardy (IJ) on 10/05/24 at 4:40 p.m. The Administrator was notified. The Administrator was provided the IJ template on 10/05/24 at 4:45 p.m. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 10/06/24 at 1:50 p.m. and reflected the following: Action: On 10/05/24 R1 was immediately placed on q 15-minute checks for close monitoring for further behaviors. R1 will remain on q 15-minute checks until IDT team meets in 30 days and reevaluate his behaviors for medical adjustment and determine if R1 will remain on q 15-minute checks or can be discontinued. If Res #1 has additional behaviors, he will be placed one-on-one until psychiatric services can reevaluate his behaviors. Res #1 was placed on q 15 minutes checks due to the recurrent behaviors that require closer monitoring. Charge nurse/nurse managers Immediately assessed R2 and the rest of the residents in the secure unit for possible mental, physical, or sexual abuse, no additional mental health needs were identified, nor any suspected physical abuse found at this time. 0 out of 10 residents were affected. Administrator/abuse coordinator Immediately in-service all staff 100% completion on Abuse & Neglect policy. for types of abuse (physical, sexual, mental, verbal, neglect, exploitation, and misappropriation) through verbal in-service and written test. Staff were also reeducated for the identification, and intervention in a situation in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur. This education included protecting and/or removing the resident from the situation, as well as who the abuse coordinator is, when to report, and how to report abuse. Staff were reeducated to stay with the aggressor until further instruction from the abuse coordinator and/or until the evaluation or further intervention. on 10/05/24 the Administrator, reeducated 100% of staff on behavioral management policy which included resident to resident abuse in regard to residents exhibiting sexual behaviors towards other and steps to do and approach the situation. Reeducation was provided for the staff with instructions for proper documentation for the behavior monitoring log through verbal in-service with monitoring log attached. Staff were reeducated through verbal in-servicing, tests, and questionnaires. On 10/05/24 MDS nurse immediately reviewed and updated care plan to reflect sexually inappropriate behaviors. The MDS nurse will review all incident reports related to sexual behaviors to make sure interventions were in place, for the floor staff to be able to see in electronic health record (EHC). Administrator/and or designee will reeducate floor staff to review Kardex in PCC (EHC) for updated interventions for each resident. On 10/06/24 at 11:48 a.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During interviews conducted on 10/06/24 from 11:05 a.m. though 3:48 p.m. included LVN EE 6:00 a.m. - 6:00 p.m. weekends, LVN FF (6:00 a.m. to 6:00 p.m.) weekends, LVN B (6:00 a.m. 2:00 p.m.), LVN GG (2:00 p.m. to 10:00 p.m.), LVN HH (10:00 p.m. to 6:00 a.m.), LVN X (10:00 p.m. to 6:00 a.m.), MA J (6:00 a.m. to 2:00 p.m & 2:00 p.m. to 10:00 p.m., CNA CC (6:00 a.m. to 2:00 p.m.), CNA E (6:00 a.m. to 2:00 p.m.), CNA JJ (6:00 a.m. to 2:00 p.m.), CNA KK (6:00 a.m. to 2:00 p.m.), CNA LL (6:00 a.m. to 2:00 p.m.), CNA D (2:00 p.m. to 10:00 p.m.), CNA MM (2:00 p.m. to 10:00 p.m.), CNA NN (10:00 p.m. to 6:00 a.m.), and CNA OO (10:00 p.m. to 6:00 a.m.), CNA PP (10:00 p.m. to 6:00 a.m.), Dietary Aide QQ, Housekeeper RR, Occupational Therapist SS, Staffing LVN TT and ADON who worked all shifts. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the Administrator and were able to give examples of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/or identified, such as immediately removing residents from the situation and stay with the aggressor one-on one until further instruction from the Abuse Coordinator. They verbalized proper documentation of behavior monitoring logs. CNA CC and CNA E said they were now aware of Resident #1's sexual behaviors and the resident was to be monitored q15 minutes. They said they documented every 15 minutes on Resident #1's behavior monitoring log. CNA CC and CNA E said they were in-serviced on abuse/neglect and gave examples of physical, verbal, and sexual abuse. They said the Administrator was the Abuse Coordinator and they would immediately report any abuse/neglect allegations to the Administrator. CNA CC and CNA E gave examples of immediate interventions they would take when an allegation or made incuding removing residents from the situation and staying with the aggressor one on one until the Administrator was notifed and gave further instruction. During an interview on 10/06/24 at 3:55 p.m., the Administrator said she had conducted in-services with all staff addressing the facility abuse/neglect policy and initiating one-on-one monitoring with the aggressor until they were given further instructions on monitoring. She had addressed the different types of abuse and staff had passed a written test. She said she instructed staff on documentation in behavior monitoring logs. She in-serviced staff on the facility's behavioral management policy which included resident abuse. She said staff were required to pass behavioral management test. She said Resident #1's care plan had been updated and a q15 minute monitoring was required by staff until the IDT meeting in 30 days to re-evaluate his behaviors. During an observation and interview on 10/06/24 at 1:15 p.m., Resident #1 was in the TV room with CNA E with no sexual behaviors noted. CNA E said she was assigned to monitor Resident #1 because he was being monitored q15 minutes for sexual behaviors and she was observed documenting the checks on his behavioral monitoring log. Record review of behavioral monitoring logs for Resident #1 indicated he was being monitored by staff every 15 minutes beginning on 10/05/24 at 6:00 p.m. to monitor for sexually inappropriate behaviors. Record review of a check off list of secured unit residents indicated all residents on the secure unit were assessed by charge nurses and the ADON. Record review of nursing assessments completed by the ADON and charge nurses for Resident #4 and all other secure unit residents indicated all residents were assessed for physical and psychosocial changes on 10/05/24. There was no evidence of sexual abuse noted on the assessments. Record review of Resident #1's care plan indicated it was updated on 10/05/24 and included he exhibiting unwanted sexual behaviors with interventions of referral to psychiatric services and increased monitoring for behaviors and changes in mental status. Record review of Resident #4's care plan indicated it was updated on 10/05/24. Record review of facility incident/accident reports indicated no other incidents of inappropriate sexual behaviors. Record review of quiz results, dated 10/05/24 and 10/06/24, indicated all staff passed the quiz regarding abuse, neglect, reporting, and one-on-one monitoring. Record review of a list of all facility staff used for tracking the required in-service training on abuse/neglect, behavioral monitoring, and behavioral management indicated all facility staff had received the in-service training in person or by phone. The Administrator was informed the IJ was removed on 10/06/24 at 3:58 p.m. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental or psychosocial status for 2 of 7 residents (Resident #1 & #2) reviewed for resident rights. The facility failed to ensure Resident #1's physician and responsible party were immediately notified on 04/19/24 after Resident #1 placed a pillow over Resident #2's face and said she tried to kill her. The facility failed to ensure Resident #2's physician was immediately notified on 04/19/24 after she reported Resident #1 had put a pillow over her face while she was sleeping and tried to kill her. On 04/22/24 at 11:03 a.m., an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 04/23/24, the facility remained out of compliance at a severity level with potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk of a delay in medical intervention and decline in health or possible worsening of symptoms. Findings included: 1. Record review of Resident #1's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included schizophrenia (a serious mental condition involving breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion), persistent mood [affective] disorder (marked disruptions in emotions {severe lows called depression or highs called hypomania or mania]), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident #1's care plan, dated 10/25/23, indicated Resident #1 had a diagnosis of schizophrenia and was at risk for manic episodes and increased behaviors. Interventions included monitor for delusions and hallucinations and monitor for increased agitation, anger, verbal, and physical aggression and document in clinical record. Resident #1 was taking psychotropic medication and was at risk for adverse reactions and depression, anxiety, and/or psychosis driven behaviors. Interventions included monitor for anxiety driven behaviors and report any noted behaviors to MD for further orders. Record review of Resident #1's quarterly MDS assessment, dated 04/08/24, indicated Resident #1 was able to make herself understood and usually understood others, and had moderate cognitive impairment indicated by a BIMS score of 11. She had had no hallucinations, delusions, or physical or verbal behaviors. She required partial to moderate assistance with most ADLs. Record review of Resident #1's clinical file revealed there were no care plans available for review related to homicidal ideations. Record review of a clinical note dated 04/20/24 at 09:59 a.m., and completed by the DON, indicated she spoke with behavioral hospital to initiate referral process due to Resident #1's aggressive behaviors towards other residents. Spoke over the phone with Resident #1's POA to inform of behaviors and sending resident to a behavioral hospital. Verbal consent given by POA. NP for physician also in agreement. Record review of a late entry clinical note dated 04/20/24, at 10:30 a.m., and completed by LVN A, indicated LVN A was notified by CNA B that Resident #2 was yelling for help as Resident #1 had placed a pillow over Resident #2's face and held it over her face. Resident #2 came out of her room yelling for help. Residents were separated and assessed with no bruising to Resident #2's face or complaints of shortness of breath. Resident #1 stated, don't send me to jail please send me to a mental institution. Resident #2 was moved to another room for her protection and safety. Paged on call physician and awaiting response. 2. Record review of Resident #2's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility 12/05/23. Resident #2 had diagnosis which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning) with agitation, major depressive disorder (a metal health disorder characterized by persistently depressed mood causing significant impairment in daily life), and schizophrenia. Record review of Resident #2's quarterly MDS dated [DATE] indicated Resident #2 was able to make herself understood and understood others, and had severe cognitive impairment indicated by a BIMS score of 6. She had feelings of being down, depressed, and hopeless 2-6 (several) days and had no behaviors. Record review of Resident #2's care plan, dated 07/31/23 indicated Resident #2 had an altered thought process and was at risk for further decline and injury as evidenced by dementia and short- and long-term memory deficit. Interventions included keep resident and others safe and monitor for mental status changes. During a telephone interview on 04/20/24 at 08:40 a.m., the Administrator said she received a text from LVN A on 04/19/24 at approximately 06:00 a.m., when she woke up reporting that Resident #1 had placed a pillow over Resident #2's face and Resident #1 was requesting to go to a mental institution. She said her immediate action had been to request an additional CNA from her corporate office and she had just received approval for the CNA this morning but had not hired a new CNA yet. The Administrator said LVN A's text indicated she had called the MD but had not received a response. The Administrator said she was not sure if the MD or Resident #1's RP had been notified about the incident. During an observation and interview on 04/20/24 at 09:10 a.m., Resident #1 was alone in her room on the secure unit resting in bed. She said yesterday (04/19/24) her roommate (Resident #2) was trying to put spells on her, and she had to stop her. She said she tried to hurt Resident #2. Resident #1 would not say how she tried to hurt Resident #2. During an observation and interview on 04/20/24 at 09:15 a.m., Resident #2 was alone in her room on the secure unit lying in bed. She said she had to be moved to a new room because her previous roommate had put a pillow over her face and tried to kill her while she was sleeping. She said she felt as safe as she could in her present surroundings. During an interview on 04/20/24 at 09:35 a.m., the DON said she was not at the facility on 04/19/24 because she had to work the night shift last night. She said she was notified on 04/19/24 that Resident #1 put a pillow over Resident #2's face, but she was now looking back on what was done after the incident. She said LVN A reported the incident, but there was no documentation in the clinical notes that she notified the MD or Resident #1's RP. The DON said Resident #2 was her own RP. The DON said notifications should have been made immediately after the incident, but she was notifying the physician and Resident #1's RP now. During a telephone interview on 04/20/24 at 9:55 a.m., LVN A said on 04/19/24 at 03:30 a.m., CNA B called her and reported that Resident # 1 had placed a pillow over Resident #2's face and tried to smother her. She said CNA B had separated the residents when she arrived on the secure unit. She said she assessed Resident #2 who had no visible injuries, but she kept repeating she tried to kill me. LVN A said Resident #1 admitted she tried to kill Resident #2. LVN A said she did not notify Resident #1's RP about the incident. LVN A said she paged the MD twice but did not receive a response. She said she gave report to LVN C about the incident and that she had not received a return call from the MD. LVN A said she assumed LVN C would notify the MD. LVN A said she had not documented her attempts to notify the MD. During an interview on 04/20/24 at 10:05 a.m., LVN C said he received report from LVN A on 04/19/24 at 06:00 a.m. about the incident between Resident #1 and Resident #2. He said LVN A reported to him she had paged the MD twice and not received a response. He said he did not try to notify the MD or Resident #1's RP about the incident on 04/19/24. During an interview on 04/20/24 at 10:51 a.m., the DON said she notified the NP of the incident that occurred on 04/19/24 to the NP and Resident #1's RP on 04/20/24 at approximately 10:00 a.m. She said she had completed the referral to the behavioral hospital for Resident #1 and was awaiting her transfer. She said the NP gave no new orders for Resident #2. During an interview on 04/20/24 at 02:30 p.m., the DON said she expected all resident changes of condition to be reported immediately to the MD and the resident's RP. She said not reporting these changes could result in harm to the resident or a further decline in the resident's physical or emotional health. During a telephone interview on 04/20/24 at 3:25 p.m., the MD said he did not receive any pages on 04/19/24 and the incident of Resident #1 putting a pillow over the face of Resident #2 had not been reported to him. The MD said if the incident had been reported to him, he would have given orders to transfer Resident #1 to a behavioral hospital. During an observation and interview on 04/20/24 at 02:59 p.m., Resident #1 was walking with ambulance attendants and the DON to an awaiting ambulance. The DON said Resident #1 was being transferred to a behavioral hospital. During a telephone interview on 04/22/24 at 11:15 a.m., the NP said she was notified on 04/20/24 at 09:57 a.m. by the DON of the incident that happened on 04/19/24 when Resident #1 had put a pillow over the face of Resident #2 and admitted to trying to kill her. NP said she gave an order to the DON to transfer Resident #1 to a behavioral hospital. During a telephone interview on 04/22/24 at 11:23 a.m., Resident #1's RP said he was notified of Resident #1 putting a pillow over Resident #2's face by the DON the morning of 04/20/24 and gave the DON his permission to send Resident #1 to a behavioral hospital. Record review of the facility's undated Change in Resident's Condition or Status policy, Indicated Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (for example, changes in level of care, billing/payments, resident rights, et cetera). This was determined to be an Immediate Jeopardy (IJ) on 04/22/24 at 08:40 a.m. The Administrator was notified. The Administrator was provided with the IJ template on 04/22/24 at 11:03 a.m. The following Plan of Removal submitted by the facility was accepted on 04/23/24 at 08:08 a.m. Immediate Action: -On 4-20-24 Director of Nursing called Responsible party and the Physician to notify him of the incident involving R1 and R2 on 4-19-24. New orders received to send R1 to inpatient psychiatric hospital. -On 4-22-24 ADON re-educated all nurses on notification policy and what steps to take if the incident occurs as outlined in the change of condition policy. 100% compliance was completed. -On 4-22-24 ADON and Administrator reviewed all new physician orders incident reports and progress notes to make sure any changes in conditions physician were notified. 3 residents were identified as having a change in condition and the physician and responsible party was notified immediately, new orders to be sent to Behavior hospital on all. In-Services All licensed nursing staff were in-serviced on immediate notification of the MD, the RP, the Administrator, and the DON of any mental or physical change in a resident's condition. The ADON completed in-service on the facility's Change in a Resident's Condition or Status policy on 04/22/24. Monitoring On 04/22/24 the Administrator and the ADON reviewed all new physician orders, incident reports, and progress notes to ensure the physician was notified of any change in resident condition. Monitoring of the POR included the following: During interviews on 04/22/24 from 4:00 p.m. through 6:00 p.m. and 04/23/24 from 9:15 a.m. through 10:15 a.m. with LVN A 10 p.m. - 6 a.m., LVN C (6:00 a.m. to 2:00 p.m.), LVN D (6:00 a.m. -2:00 p.m.), LVN E (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.), LVN F (10:00 p.m. to 6:00 a.m.), LVN G (10 p.m. to 10 p.m.), LVN H (2:00 p.m. to 10:00 p.m., LVN I (2:00 a.m. to 10 p.m.), RN J (weekend shifts), and LVN K (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.) and the ADON indicated staff were able to identify the Abuse Coordinator as the administrator. Licensed staff all indicated they were educated on reporting any change of resident condition immediately to the Administrator, DON, MD, and RP. All staff verbalized knowledge of examples of changes in resident condition such as an accident or incident involving the resident, injury of an unknown source, change in the resident's physical/emotional/mental condition, or adverse reactions to medications. The ADON indicated all licensed staff had received in-service training either in person, by email, or be text. During an interview on 04/23/24 at 10:20 a.m., the Administrator said she was in-serviced on 09/22/24 by the Regional Director of Clinical Operations (RCDO). She was able to verbalize the facility change of condition policy and the facility would conduct a thorough investigation of all incidents of resident verbal or physical aggression to others. She said the physician would be notified immediately of any change of condition of any resident. She and the DON would be in-serviced on the change of condition policy upon her return to the facility. She said The DON and ADON would conduct audits daily of any new physician orders, incident reports, progress notes and the 24-hour report to ensure every change in resident condition was reported to the MD and the RP. During an interview on 04/23/24 at 10:25 a.m., the ADON said she was in-serviced on 04/22/24 by the RDCO. She was able to verbalize the facility change of condition policy and the facility would conduct a thorough investigation of all incidents of resident verbal or physical aggression to others. She said the physician would be notified immediately of any change of condition of any resident. She and the DON would be in-serviced on the change of condition policy upon her return to the facility. She said The DON and the ADON would conduct audits daily of any new physician orders, incident reports, progress notes and the 24-hour report to ensure every change in resident condition was reported to the MD and the RP. Record review of all incidents from the previous 90 days indicated there were no additional incidents of resident change of condition not being reported to the MD and the RP. Record review of training records indicated all Licensed staff were in-serviced on 04/22/24 regarding the facility change in resident condition policy, the procedure for reporting any change in resident condition to the resident RP, and physician notification. The Administrator and the ADON were informed the Immediate Jeopardy was removed on 04/23/24 at 10:35 a.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to ensure residents the right to be free from abuse for 2 of 7 residents (Residents #2 and #3) reviewed for abuse. 1. On 04/03/24 Resident #3 self-propelled her wheelchair into Resident #1's room and Resident #1 pulled Resident #3 out of her wheelchair onto the floor. 2. On 04/19/24 Resident #1 placed a pillow over the face of Resident #2 and later admitted she was trying to kill Resident #2. On 04/20/24 at 02:29 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 04/21/24, the facility remained out of compliance at a severity level with the potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of thei Plan of Removal. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of Resident #1's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included schizophrenia (a serious mental condition involving breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion), persistent mood [affective] disorder (marked disruptions in emotions {severe lows called depression or highs called hypomania or mania]), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident #1's care plan, dated 10/25/23, indicated Resident #1 had a diagnosis of schizophrenia and was at risk for manic episodes and increased behaviors. Interventions included monitor for delusions and hallucinations and monitor for increased agitation, anger, verbal, and physical aggression and document in clinical record. Resident #1 was taking psychotropic medication and was at risk for adverse reactions and depression, anxiety, and/or psychosis driven behaviors. Interventions included monitor for anxiety driven behaviors and report any noted behaviors to MD for further orders. Record review of Resident #1's care plan, dated 10/25/23, indicated Resident #1 was taking psychotropic medication and was at risk for adverse reactions and depression, anxiety, and/or psychosis driven behaviors. Interventions included monitor for anxiety driven behaviors and report any noted behaviors to MD for further orders. Record review of Resident #1's quarterly MDS assessment, dated 04/08/24, indicated Resident #1 was able to make herself understood and usually understand others, and had moderate cognitive impairment indicated by a BIMS score of 11. She had had no hallucinations, delusions, or physical or verbal behaviors. She required partial to moderate assistance with most ADLs. Record review of Resident #1's clinical file revealed there were no care plans available for review related to homicidal ideations. Record review of the incident report dated 04/19/24 at 03:40 a.m., completed by LVN A indicated she was notified by CNA B that Resident #2 was yelling for help because Resident #1 (her roommate) had placed a pillow over Resident #2's face and held it over her face. Resident #2 came out of her room yelling for help. The residents were separated, and Resident #2 was assessed with no bruising on her face and no shortness of breath. Resident #1 admitted she did it and stated, Don't send me to jail please send me to a mental institution. Resident #2 was moved to another room for her protection and safety. MD was paged and LVN A was awaiting response. Administrator was notified. 2. Record review of Resident #2's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility 12/05/23. Resident #2 had diagnosis which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning) with agitation, major depressive disorder (a metal health disorder characterized by persistently depressed mood causing significant impairment in daily life), and schizophrenia. Record review of Resident #2's care plan, dated 07/31/23 indicated Resident #2 had an altered thought process and was at risk for further decline and injury as evidenced by dementia and short- and long-term memory deficit. Interventions included keep resident and others safe and monitor for mental status changes. Record review of Resident #2's quarterly MDS dated [DATE] indicated Resident #2 was able to make herself understood and understood others, and had severe cognitive impairment indicated by a BIMS score of 6. She had feelings of being down, depressed, and hopeless 2-6 (several) days and had no behaviors. During a telephone interview on 04/20/24 at 08:40 a.m., the Administrator said she received a text from LVN A on 04/19/24 at approximately 06:00 a.m. when she woke up reporting Resident #1 had placed a pillow over Resident #2's face and Resident #1 was requesting to go to a mental institution. She said her immediate action had been to request an additional CNA for the secure unit from her corporate office and she had just received approval for the CNA this morning but had not hired a new CNA yet. The Administrator said the secure unit had one dedicated CNA and one nurse that floats between the other rooms and the secure unit. She said Resident #2 had been moved into another room on the secure unit. During an observation and interview on 04/20/24 at 09:05 a.m., CNA L said she was assigned the secure unit today with LVN C who was floating between the secure unit and rooms outside the unit. CNA L was sitting in the TV room with 4 residents and said Residents #1 and #2 were in their rooms alone. During an observation and interview on 04/20/24 at 09:10 a.m., Resident #1 was alone in her room on the secure unit and resting in bed. She said yesterday (04/19/24) her roommate (Resident #2) was trying to put spells on her, and she had to stop her. She said she tried to hurt Resident #2. During an observation and interview on 04/20/24 at 09:15 a.m., Resident #2 was alone in her room on the secure unit lying in bed. She said she had to be moved to a new room because her previous roommate had put a pillow over her face and tried to kill her while she was sleeping. She said she felt as safe as she could in her present surroundings. During an interview on 04/20/24 at 09:35 a.m., the DON said she was not at the facility on 04/19/24 because she had to work the night shift last night. She said was notified on 04/19/24 about Resident #1 putting a pillow over Resident #2's face, but she was now looking back on what was done after the incident. She said LVN A reported the incident, but there was no documentation in the clinical record about the incident or if LVN A notified the police, the physician, or the responsible party. She said notifications should have been made and she was doing the notifications to the MD and RP. She said based on the aggression Resident #1 should have been transferred to a behavioral hospital for evaluation. During a telephone interview on 04/20/24 at 09:55 a.m., LVN A said on 04/19/24 at 03:30 a.m. she received a call from CNA B who reported Resident #1 had placed a pillow over Resident #2's face and tried to smother her. She said CNA B had separated the residents when she arrived on the secure unit. LVN A said she assessed Resident #2 and found no visible injuries, but she kept repeating she tried to kill me. She said Resident #1 admitted she tried to kill Resident #2. LVN A said she paged the MD twice and he did not call by the end of her shift. She said she reported the incident to her Administrator via text and LVN C who was the nurse working the 06:00 a.m. to 02:00 p.m. shift. During an interview on 04/20/24 at 10:05 a.m., LVN C said he received report from LVN A on 04/19/24 at 06:00 a.m. about the incident between Resident #1 and Resident #2. He said LVN A reported to him she had paged the MD twice and not received a response. He said he did not try to notify the MD or Resident #1's RP about the incident on 04/19/24. He said he never noticed if Resident #1 ever came out of her room on his shift and he wasn't sure if Resident #2 was in or out of her room during the day. During a telephone interview on 04/20/24 at 10:21 a.m. CNA B said on 04/19/24 at approximately 03:20 a.m. she was passing by the room Resident #1 and Resident #2 shared when Resident #2 ran out of the room saying Resident #1 put a pillow over her head and tried to kill her. Resident #1 said Resident #2 had been naked during the day and she tried to kill her. Resident #1 then said she wanted to go to a mental hospital in Dallas because that was where her brother sent her whenever she tried to hurt people. CNA B said she separated the residents by bringing Resident #2 into the TV room with her and called LVN A and reported the incident. CNA B said after the incident Resident #1 was pacing up and down the hall talking loudly but not making any sense. She said then Resident #1 went into her room and pulled the mattress off her bed and disrobed and continued pacing around her room. She said Resident #2 said she was afraid to be alone in her room, so CNA B kept Resident #2 with her the rest of the night except when assisting other residents and she took her to sit with LVN A. During an interview on 04/20/24 at 10:51 a.m., the DON said she notified the NP of the incident that occurred on 04/19/24 to the NP and Resident #1's RP on 04/20/24 at approximately 10:00 a.m. She said she had completed the referral to the behavioral hospital for Resident #1 and was awaiting her transfer. She said the NP gave no new orders for Resident #2. During an observation and interview on 04/20/24 at 11:19 a.m., Police Officer M visited Resident #2 in her room. Resident #2 remained alone in her room made a verbal statement to Police Officer M that Resident #1 had tried to kill her by placing a pillow over her face while she was sleeping. She said she wanted to press charges against Resident #1 so she wouldn't try to kill her again. During an observation on 04/20/24 at 11:26 a.m., Resident #1 was sleeping alone in her room. During an interview on 04/20/24 at 03:59 p.m., the DON said she sat with Resident #1 until she was transported by ambulance to a behavioral hospital at approximately 03:30 p.m. 3. Record review of Resident #3's face sheet dated 04/20/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included cerebral infarction (stroke), spastic hemiplegia (a common post-stroke condition that causes stiff or rigid muscles) affecting right dominant side, vascular dementia (dementia [a condition characterized by progressive or persistent loss of intellectual functioning] caused by an impaired supply of blood to the brain), mood disorder (marked disruptions in emotions [severe lows called depression or highs called hypomania or mania]), and depression Record review of Resident #3's care plan revised on 06/21/23 indicated Resident #3 was deemed at risk for wandering related to being ambulatory with her wheelchair, diagnosis of dementia, and history of exit seeking. Goals included Resident #3 would be able to wander in a safe environment (secure unit) with no occurrence of injury and dignity would be maintained. Record review of Resident #3's annual MDS dated [DATE] indicated Resident #3 was sometimes able to make herself understood and usually understood others, and had severe cognitive impairment indicated by a staff assessment. She had mood of little interest or pleasure in doing things several (2-6 days) and behaviors directed toward others 1 to 3 days and no wandering behaviors. Record review of Resident #1's clinical note (related to the incident with Resident #3) dated 04/03/24 at 11:30 a.m. and signed by LVN N indicated a CNA B came and informed LVN N that Resident #1 pulled Resident #3 out of her wheelchair onto the floor of Resident #1's room. Resident #1 said I'm not a fucking babysitter, I need help my motherfucking self she needs to keep her ass out of my motherfucking room. On arrival to the secure unit residents were already separated and in different rooms. LVN N educated and redirected Resident #1, she was informed that physical aggression would not be tolerated, and it was not her right to put hands on anyone. LVN A indicated that Resident #1 did not verbalize understanding. During an observation and interview on 04/20/24 at 09:05 a.m., Resident #3 was sitting in the TV room of the secure unit. She was unable to answer question about the incident. She was holding her right arm against her, and it appeared to have contractures at her elbow and wrist. Resident #3 said her arm was not painful. CNA L said Resident #3's arm was paralyzed from a stroke. CNA L said staff tried to keep Resident #3 busy because she wandered into other resident's rooms. She said she was not working the day Resident #3 wandered into Resident #1's room and Resident #1 pulled her out of her wheelchair to the floor, but it had been reported to her by another CNA. During an interview on 04/20/24 at 09:35 a.m. the DON said the only reason Resident #1 had pulled Resident #3 out of her wheelchair on 04/03/24 was because she went into Resident #1's room. She said she had instructed all staff on the secure unit to keep Resident #3 from wandering into other resident's rooms. During a telephone interview on 04/22/24 at 11:35 a.m., LVN N said on 04/03/24 at approximately 11:30 a.m., a CNA reported to her that Resident #3 had self-propelled her wheelchair into Resident #1's room and Resident #1 pulled her out of her wheelchair and onto the floor. LVN N said she assessed Resident #3 who was sitting in the floor of Resident #1's room at the foot of her bed. She had no visible injuries, and she was assisted back into her wheelchair and out of the room. Resident #3 was unable to say how she got onto the floor. LVN N said she notified the ADON, the Administrator, the MD, and the RP of the incident. During a telephone interview on 04/22/24 at 12:16 p.m., Resident #3's RP said she was notified on 04/03/24 by the nurse that Resident #3 had wheeled herself into another resident's room and the other resident had pulled Resident #3 out of her wheelchair and onto the floor. She said Resident #3's right arm had paralysis since her stroke. She said Resident #3 had no bruising or pain after she was pulled from her wheelchair. RP said she visited Resident #3 every day and she had witnessed residents on the secure unit being aggressive to staff and other residents. RP said she could not name the Residents she had seen be aggressive, but she had seen Resident #1 yell and cuss at other residents. She said she had not told the Administration about resident aggression. Record review of the facility's Abuse and Neglect Policy dated June 2023 indicated It is the policy of the facility to administer care and services in an environment that is free of any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment .The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal guidelines of prevention and investigation .VI. Protect residents from physical and psychosocial harm during investigations. This was determined to be an Immediate Jeopardy (IJ) on 04/20/24 at 02:25 p.m. The Administrator was notified. The Administrator was provided the IJ template on 04/20/24 at 2:29 p.m. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/21/24 at 10:37 a.m. and reflected the following: Immediate action: On 4/20/24 Resident #1 was immediately placed on 1 on 1 monitoring until the facility could transfer Resident #1 to psychiatric hospital, waiting on approval from the behavioral hospital to transport. *Charge nurse/ nurse managers Immediately assessed Resident #2 & Resident #3 and the rest of the residents in the secure unit for possible mental or physical abuse, no additional mental health needs were identified, nor any suspected physical abuse found at this time. oAdministrator/abuse coordinator Immediately in-serviced all staff 100% completion on Abuse & Neglect policy. o on 4/20/24 the Director of Nursing, Inservice all 100% of staff on behavioral management policy which included resident to resident abuse regarding residents exhibiting aggressive behaviors towards others, and steps to do, and how to approach the situation. On 4/21/24 the MDS nurse reviewed all residents who have had aggressive behaviors, to make sure interventions were in place, for the floor staff to be able to see in electronic health record (EHR). The facility reviewed the system for abuse identification and reporting. The facility created a plan of improvement to assure residents were free from abuse to address changes including education, daily chart reviews and IDT discussions. The DON and/or Designee will review incident reports and progress notes 5 days weekly to assure that there were no incidents that could meet the qualifications of abuse and discuss any concerns with the abuse coordinator immediately. Resident #1 was placed on one-on-one monitoring until her transfer to a behavioral on 04/20/24. The charge nurses and the nurse managers reviewed all residents on the secure unit on 04/20/24 that were involved in incidents within the last 30 days to ensure all residents had the correct supervision. No additional mental or physical abuse was identified. On 04/20/24 the Administrator completed in-service with all facility staff regarding the behavioral management policy which included resident to resident abuse, residents exhibiting aggressive behaviors, and steps to approach a resident-to-resident situation. On 04/21/23 at 11:48 a.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During interviews conducted on 04/20/24 from 03:30 p.m. though 06:00 p.m. and 04/21/24 from 08:15 a.m. 11:48 a.m. included LVN A 10 p.m. - 6 a.m., LVN C (6:00 a.m. to 2:00 p.m.), LVN D (6:00 a.m. -2:00 p.m.), LVN E (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.), LVN F (10:00 p.m. to 6:00 a.m.), LVN G (10 p.m. to 10 p.m.), LVN H (2:00 p.m. to 10:00 p.m., LVN I (2:00 a.m. to 10 p.m.),RN j (weekend shifts), and LVN K (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.), CNA B (10:00 p.m. to 6:00 a.m.), CNA L (6:00 a.m. to 2:00 p.m.), CNA O (6:00 a.m. to 2:00 p.m.), CNA P (2:00 p.m. to 10:00 p.m.), CNA Q (2:00 p.m. to 10:00 p.m.), CNA R (10:00 p.m. to 6:00 a.m.), and CNA S (6:00 a.m. to 2:00 p.m.), the Dietary Manager, Dietary Aide T, Dietary Aide U, Housekeeper V, Housekeeper W, MDS Nurse and 1 ADON who worked all shifts. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/or identified, such as immediately removing the alleged perpetrators from providing care to residents and separating residents. Staff were educated on facility posting related to reporting abuse were able to locate numbers for reporting and alternate methods of reporting abuse such as department supervisors and/ or charge nurses. During an interview on 04/21/24 at 10:20. a.m., the Administrator and the DON indicated the facility 24 Hour Report and Incident Reports would be reviewed in the morning clinical meetings attended by the Administrator and the Director of Nursing to review for any allegations or instances of abuse and/ or neglect. The weekend manager on duty and weekend RN Supervisor would report any incidents or allegations to the DON and administrator immediately. The Administrator was informed the IJ was removed on 04/21/24 at 12:39 a.m. The facility remained out of compliance at potential for more than minimal harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 7 residents (Resident #1) reviewed for accidents and supervision. The facility failed to place Resident #1 on one-on-one supervision or move her to a private room after she pulled Resident #3 out of her wheelchair after Resident #3 self-propelled her wheelchair into Resident #1's room. The facility failed to place Resident #1 on one-on-one supervision after Resident #1 tried to kill Resident #2 (her roommate) by placing a pillow over her face. On 04/20/24 at 02:29 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 04/21/24, the facility remained out of compliance at a severity level with the potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk of abuse, physical harm, mental anguish, emotional distress, and death. Findings included: 1. Record review of Resident #1's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included schizophrenia (a serious mental condition involving breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion), persistent mood [affective] disorder (marked disruptions in emotions {severe lows called depression or highs called hypomania or mania]), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident #1's care plan, dated 10/25/23, indicated Resident #1 had a diagnosis of schizophrenia and was at risk for manic episodes and increased behaviors. Interventions included monitor for delusions and hallucinations and monitor for increased agitation, anger, verbal, and physical aggression and document in clinical record. Resident #1 was taking psychotropic medication and was at risk for adverse reactions and depression, anxiety, and/or psychosis driven behaviors. Interventions included monitor for anxiety driven behaviors and report any noted behaviors to MD for further orders. Record review of Resident #1's quarterly MDS assessment, dated 04/08/24, indicated Resident #1 was able to make herself understood and usually understand others, and had moderate cognitive impairment indicated by a BIMS score of 11. She had had no hallucinations, delusions, or physical or verbal behaviors. She required partial to moderate assistance with most ADLs. Record review of Resident #1's clinical file revealed there were no care plans available for review related to homicidal ideations. Record review of Resident #1's clinical note (related to the incident with Resident #3) dated 04/03/24 at 11:30 a.m. and signed by LVN N indicated CNA came and informed LVN N that Resident #1 pulled Resident #3 out of her wheelchair onto the floor of Resident #1's room. Resident #1 said I'm not a fucking babysitter, I need help my motherfucking self she needs to keep her ass out of my motherfucking room. On arrival to the secure unit residents were already separated and in different rooms. LVN N educated and redirected Resident #1, she was informed that physical aggression would not be tolerated, and it was not her right to put hands on anyone. LVN A indicated that Resident #1 did not verbalize understanding. Record review of a psychiatric services visit note completed on 04/17/24 at 11:01 a.m. and signed by the NP indicated Resident #1 was being seen for schizophrenia and anxiety. Goals for treatment included compliance with treatment plan, reduced risk of assaultive or inappropriate behaviors, reduction of psychotic thinking, stabilization of anxious/irritable mood, stabilization of cognitive problems, stabilization of depressed mood, increased interpersonal interactions and reduced withdrawal. Resident #1 had shown mild improvement in response to treatment. Record review of the incident report dated 04/19/24 at 03:40 a.m., Completed by LVN A indicated she was notified by CNA B that Resident #2 was yelling for help because Resident #1 (her roommate) had placed a pillow over Resident #2's face and held it over her face. Resident #2 came out of her room yelling for help. The residents were separated, and Resident #2 was assessed with no bruising on her face and no shortness of breath. Resident #1 admitted she did it and stated, Don't send me to jail please send me to a mental institution. Resident #2 was moved to another room for her protection and safety. MD was paged and LVN A was awaiting response. Administrator was notified. During a telephone interview on 04/20/24 at 08:40 a.m., the Administrator said she received a text from LVN A on 04/19/24 at approximately 06:00 a.m. when she woke up reporting Resident #1 had placed a pillow over Resident #2's face and Resident #1 was requesting to go to a mental institution. She said her immediate action had been to request an additional CNA for the secure unit from her corporate office and she had just received approval for the CNA this morning but had not hired a new CNA yet. The Administrator said the secure unit had one dedicated CNA and one nurse that floats between the other rooms and the secure unit. She said Resident #2 had been moved into another room on the secure unit. She said no other safety measures had been put in place on the secure unit. During an observation and interview on 04/20/24 at 09:05 a.m., CNA L said she was assigned the secure unit today with LVN C who was floating between the secure unit and rooms outside the unit. CNA L was sitting in the TV room with 4 residents and said Residents #1 and #2 were in their rooms alone. During an observation and interview on 04/20/24 at 09:10 a.m., Resident #1 was alone in her room on the secure unit and resting in bed. She said yesterday (04/19/24) her roommate (Resident #2) was trying to put spells on her, and she had to stop her. She said she tried to hurt Resident #2. Resident #1 could not recall trying to hurt any other residents. During an interview on 04/20/24 at 09:35 a.m., the DON said she was not at the facility on 04/19/24 because she had to work the night shift last night. She said was notified on 04/19/24 about Resident #1 putting a pillow over Resident #2's face, but she was now looking back on what was done after the incident. She said LVN A reported the incident, but there was no documentation in the clinical record about the incident or if LVN A notified the police, the physician or the responsible party. She said notifications should have been made and she was doing the notifications to the MD and RP. She said based on the aggression Resident #1 should have been transferred to a behavioral hospital for evaluation. The DON said the only reason Resident #1 had pulled Resident #3 out of her wheelchair on 04/03/24 was because she went into Resident #1's room. She said she had instructed all staff on the secure unit to keep Resident #3 from wandering into other resident's rooms, but no additional safety measures had been put in place. During an interview on 04/20/24 at 10:05 a.m., LVN C said he received report from LVN A on 04/19/24 at 06:00 a.m. about the incident between Resident #1 and Resident #2. He said he was assigned to the secure unit and other rooms outside the secure unit on the 06:00 a.m. to 02:00 p.m. shift on 04/19/24. He said he never noticed if Resident #1 ever came out of her room on his shift and he wasn't sure if Resident #2 was in or out of her room during the day. During an interview on 04/20/24 at 10:51 a.m., the DON said she notified the NP of the incident that occurred on 04/19/24 to the NP and Resident #1's RP on 04/20/24 at approximately 10:00 a.m. She said she had completed the referral to the behavioral hospital for Resident #1 and was awaiting her transfer. She said the NP gave no new orders for Resident #2. During an observation on 04/20/24 at 11:26 a.m., Resident #1 was sleeping alone in her room. Staff were assisting other residents on the secure unit with ADLs. There was no one-on-one monitoring with Resident #1. During an interview on 04/20/24 at 02:30 p.m., the DON said the facility only placed residents on one-on-one monitoring if they were homicidal or suicidal. She said Resident #1 was not placed on one-on one monitoring, but she should have been. The DON said was going to sit with Resident #1 (after surveyor intervention) until she was transported to the behavioral hospital. She said not having her under increased monitoring could result in harm to other residents on the secure unit. During a telephone interview on 04/20/24 at 3:25 p.m., the MD said he did not receive any pages on 04/19/24 and the incident of Resident #1 putting a pillow over the face of Resident #2 had not been reported to him. The MD said if the incident had been reported to him, he would have given orders to transfer Resident #1 to a behavioral hospital. During an interview on 04/20/24 at 03:59 p.m., the DON said she sat with Resident #1 until she was transported by ambulance to a behavioral hospital at approximately 03:30 p.m. 2. Record review of Resident #2's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility 12/05/23. Resident #2 had diagnosis which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning) with agitation, major depressive disorder (a metal health disorder characterized by persistently depressed mood causing significant impairment in daily life), and schizophrenia. Record review of Resident #2's care plan, dated 07/31/23 indicated Resident #2 had an altered thought process and was at risk for further decline and injury as evidenced by dementia and short- and long-term memory deficit. Interventions included keep resident and others safe and monitor for mental status changes. Record review of Resident #2's quarterly MDS dated [DATE] indicated Resident #2 was able to make herself understood and understood others, and had severe cognitive impairment indicated by a BIMS score of 6. She had feelings of being down, depressed, and hopeless 2-6 (several) days and had no behaviors. Record review of a psychiatric visit note completed on 04/17/24 at 11:01 a.m. and signed by the NP indicated Resident #2 was being seen for anxiety, dementia, depression/sadness, schizophrenia, bipolar, and insomnia. Resident #2 was oriented to person, place, month, and situation. Resident #2 exhibited a logical thought process with fair insight and judgement. She had little to no risk of aggression. Record review of Resident #2's clinical note dated 04/19/24 at 03:54 a.m. and signed by LVN A indicated she was notified by CNA that Resident #2 came running out of her room yelling for help and saying her roommate (Resident #1) placed a pillow over her face and held it over her face. The residents were separated, and Resident #2 was assessed with no bruising on her face and no shortness of breath. Resident #2 was moved to another room for her protection and safety. During an observation and interview on 04/20/24 at 09:15 a.m., Resident #2 was alone in her room on the secure unit lying in bed. She said she had to be moved to a new room because her previous roommate had put a pillow over her face and tried to kill her while she was sleeping. She said she felt as safe as she could in her present surroundings. During an observation and interview on 04/20/24 at 11:19 a.m., Police Officer M visited Resident #2 in her room. Resident #2 remained alone in her room and made a verbal statement to Police Officer M that Resident #1 had tried to kill her by placing a pillow over her face while she was sleeping. She said she wanted to press charges against Resident #1 so she wouldn't try to kill her again. During an interview on 04/22/24 at 01:45 p.m., CNA O said she worked the 06:00 a.m. to 02:00 p.m. on 04/19/24 and the incident of Resident #1 putting a pillow over Resident #2's face was reported to her by CNA B. She said Resident #1 was in a happy mood all day going into and out of the TV room listening to the music that was playing in the room. CNA O said Resident #2 said she was afraid to be in her room and stayed close to her or other residents in the TV room. She said Resident #2 kept saying, why is she still here-she tried to kill me. 3. Record review of Resident #3's face sheet dated 04/20/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included cerebral infarction (stroke), spastic hemiplegia (a common post-stroke condition that causes stiff or rigid muscles) affecting right dominant side, vascular dementia (dementia [a condition characterized by progressive or persistent loss of intellectual functioning] caused by an impaired supply of blood to the brain), mood disorder (marked disruptions in emotions [severe lows called depression or highs called hypomania or mania]), depression Record review of Resident #3's care plan revised on 06/21/23 indicated Resident #3 was deemed at risk for wandering related to being ambulatory with her wheelchair, diagnosis of dementia, and history of exit seeking. Goals included Resident #3 would be able to wander in a safe environment (secure unit) with no occurrence of injury and dignity would be maintained. Record review of Resident #3's annual MDS dated [DATE] indicated Resident #3 was sometimes able to make herself understood and usually understood others, and had severe cognitive impairment indicated by a staff assessment. She had mood of little interest or pleasure in doing things several (2-6 days) and behaviors directed toward others 1 to 3 days and no wandering behaviors. Record review of a psychiatric services visit note completed 04/10/24 at 11:06 a.m. and signed by the NP indicated Resident #3 was being seen for anxiety, dementia, and depression/sadness. Resident #3 was aphasic (unable to speak, write, or understand speech or writing because of damage to the brain) with no behavioral problems. Goals for treatment included adjustment to need for placement in facility, increased compliance with treatment plan, stabilization of anxious/irritable mood, stabilization of cognitive problems, stabilization of depressed mood, increased interpersonal interactions and reduced withdrawal. Resident had shown mild decline in response to treatment. During an observation and interview on 04/20/24 at 09:05 a.m., Resident #3 was sitting in the TV room of the secure unit. She was unable to answer question about the incident. She was holding her right arm against her, and it appeared to have contractures at her elbow and wrist. CNA L said staff tried to keep Resident #3 busy because she wandered into other resident's rooms. She said she was not working the day Resident #3 wandered into Resident #1's room and Resident #1 pulled her out of her wheelchair to the floor, but it had been reported to her by another CNA. During an interview on 04/20/24 at 09:35 a.m. the DON said the only reason Resident #1 had pulled Resident #3 out of her wheelchair on 04/03/24 was because she went into Resident #1's room. She said she had instructed all staff on the secure unit to keep Resident #3 from wandering into other resident's rooms. During an interview on 04/20/24 at 10:51 a.m., the NP said the facility notified her on 04/03/24 of the incident of Resident #1 pulling Resident #3 out of her wheelchair and onto the floor. During a telephone interview on 04/22/24 at 11:35 a.m., LVN N said on 04/03/34 at approximately 11:30 a.m., a CNA reported to her that Resident #3 had self-propelled her wheelchair into Resident #1's room and Resident #1 pulled her out of her wheelchair and onto the floor. Resident #3 was on the floor in Resident #3's room. LVN N said she assessed Resident #3 who was sitting in the floor of Resident #1's room at the foot of her bed. She had no visible injuries, and she was assisted back into her wheelchair and out of the room. Resident #3 was unable to say how she got onto the floor. LVN N said she notified the ADON, the Administrator, MD, and the RP of the incident. During a telephone interview on 04/22/24 at 12:16 p.m., Resident #3's RP said she was notified on 04/03/24 by the nurse that Resident #3 had wheeled herself into another resident's room and the other resident had pulled Resident #3 out of her wheelchair and onto the floor. RP said she visited Resident #3 every day and she had witnessed residents on the secure unit being aggressive to staff and other residents. Record review of the facility's Abuse and Neglect Policy dated June 2023 indicated VI. Protection: Have procedures to: Protect residents from physical or psychosocial harm during the investigation . 3. Attending physician will be notified. A. This includes but not limited to full assessment of physical and psychosocial well-being; sending resident to hospital if needed; depending on circumstance, keep resident on 1:1, assign a female/male depending on the accusation/allegation. Record review of the facility's undated policy Problematic Behavior Management- Clinical Protocol indicated 2. The staff will identify, document, and inform the Physician about a resident's mental status, behavior, and cognition. This will include details about any problematic behavior such as onset, frequency, and precipitating factors. This was determined to be an Immediate Jeopardy (IJ) on 04/20/24 at 02:25 p.m. The Administrator was notified. The Administrator was provided the IJ template on 04/20/24 at 2:29 p.m. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/21/24 at 10:37 a.m. and reflected the following: Action: o On 4/20/24 Resident #1 was immediately placed on 1 on 1 until the facility could transfer Resident #1 to psychiatric hospital, waiting on approval from the behavioral hospital to transport. On 4/20/24 Charge nurse/ nurse managers Immediately reviewed residents in the secure unit that have had recent incidents within the last 30 days involving resident altercation to make sure they had the correct supervision. 0 residents besides Resident #1 were identified. Charge nurse/ nurse managers Immediately assessed Resident #2 & Resident #3 and the rest of the residents in the secure unit for possible mental or physical abuse, no additional mental health needs were identified, nor any suspected physical abuse found at this time. o on 4/20/24 Administrator/ or designee Immediately in-service all staff 100% completion on behavioral management policy which included resident to resident abuse regarding residents exhibiting aggressive behaviors towards others, steps to do and how to approach the situation. o On 4/20/24 the Administrator reviewed schedules and a second CNA was added in the secure unit for extra supervision. If a resident was identified as a repeated aggressor, the facility will immediately add additional support staff in order to keep residents safe. On 4/21/24 Administrator/ DON were Inservice by Regional Director of Clinical Operations if additional staff was needed for immediate safety interventions no approval was needed from corporate to add additional staff for support. After completion of secure unit resident review/assessments on 04/20/24 by charge nurses and nurse mangers, no other residents were found to have additional mental health needs and no other suspected physical abuse was found. The facility reviewed the system for problematic behavior management. The facility created a plan of improvement to assure residents behaviors were monitored, documented, and reported to the MD. The Administrator reviewed schedules and a second CNA was added in the secure unit for extra supervision and if a resident was identified as a repeated aggressor, the facility will immediately add additional support staff in order to keep residents safe. All staff were educated on behavioral management policy which included resident to resident abuse regarding residents exhibiting aggressive behaviors towards others. steps to do and how to approach the situation. Until alternative and/or safe living arrangements were made the resident will be placed on one-on-one supervision with facility staff. Resident care plans will also be updated to include any acts of aggression or being to receiver of aggression. Monitoring of the POR included the following: During interviews conducted on 04/20/24 from 03:30 p.m. though 06:00 p.m. and 04/21/24 from 08:15 a.m. 11:48 a.m. included LVN A (10 p.m. - 6 a.m.), LVN C (6:00 a.m. to 2:00 p.m.), LVN D (6:00 a.m. -2:00 p.m.), LVN E (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.), LVN F (10:00 p.m. to 6:00 a.m.), LVN G (10 p.m. to 10 p.m.), LVN H (2:00 p.m. to 10:00 p.m., LVN I (2:00 a.m. to 10 p.m.),RN j (weekend shifts), LVN K (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.), CNA B (10:00 p.m. to 6:00 a.m.), CNA L (6:00 a.m. to 2:00 p.m.), CNA O (6:00 a.m. to 2:00 p.m.), CNA P (2:00 p.m. to 10:00 p.m.), CNA Q (2:00 p.m. to 10:00 p.m.), CNA R (10:00 p.m. to 6:00 a.m.), CNA S (6:00 a.m. to 2:00 p.m.), the Dietary Manager, Dietary Aide T, Dietary Aide U, Housekeeper V, Housekeeper W, MDS Nurse and 1 ADON who worked all shifts. Staff were able to verbalize procedure of separating residents during an act of aggression, reporting the aggression to a charge nurse, the ADON, the DON, and the Administrator. To maintain one-on one monitoring of the aggressor for the protection of other residents. Licensed staff verbalized aggression incidents should also be reported to the MD, police, and both resident's RPs. Interviews conducted with five alert residents on 04/21/24 from 8:00 a.m. to 10:00 a.m. indicated they would report abuse to the administrator or the DON. They were not afraid of any residents. During an interview on 04/21/24 at 10:20. a.m., the Administrator and the DON indicated the facility 24 Hour Report and Incident Reports would be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any allegations or instances physical aggression. The weekend manager on duty and weekend RN Supervisor would report any incidents or allegations to the DON and administrator immediately. Record review of all incidents from the previous 90 days indicated there were no additional incidents of acts of physical aggression as of 04/21/24. Record review of training records indicated all staff (nursing and non-nursing) were in-serviced on 04/20/24 and 04/21/24 regarding the facility abuse and neglect policy and the behavioral management policy, the procedure for reporting incidents and acts of aggression, suspected abuse/neglect, recognizing threats of harm (to self and others), and physician notification. The Administrator was informed the Immediate Jeopardy was removed on 04/21/24 at 12:39 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 2 residents (Resident #1) reviewed for CPR. The facility failed to ensure staff utilized the AED (automated external defibrillator- a medical device that analyzes the heart's rhythm and, if necessary, delivers an electrical shock to the heart in attempt to re-establish an effective rhythm) when Resident #1 was found on [DATE] unresponsive, not breathing, and no pulse. Resident #1 was pronounced deceased on [DATE]. An IJ was identified on [DATE] at 3:57 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving necessary life-saving measures, decline in health, and death. Findings include: Record review of Resident #1's face sheet dated [DATE] indicated he ws a [AGE] year old male admitted to the facility on [DATE] with diagnoses including type II diabetes (a disease that occurs when blood glucose, also called blood sugar, is too high), cerebral infarction (pathologic process that results in an area of necrotic tissue in the brain), chronic combined systolic and diastolic congestive heart failure (systolic CHF, the ventricles cannot produce enough pressure in the contraction phase to push blood into circulation, diastolic CHF, the ventricles cannot relax, expand, or fill with enough blood-combined CHF is a combination of the two), hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure, acute kidney failure (kidneys are suddenly not able to filter waste products from the blood), hyperlipidemia (also known as high cholesterol, means too many lipids (fats) in the blood), morbid obesity, hypokalemia (low blood potassium levels), respiratory failure with hypoxia (not have enough oxygen in your blood), and angina pectoris (chest pain or discomfort due to coronary heart disease). The face sheet indicated Resident #1 was a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive. This process can include chest compressions, artificial ventilation and defibrillation and is referred to as CPR.). Record review of Resident #1's quarterly MDS dated [DATE] indicated he had clear speech, was usually understood and usually understood others, he had moderate impaired cognitive function (BIMS score 11). Record review of Resident #1's care plan dated [DATE] (revised [DATE]) indicated Resident #1's RP requested full code status. Interventions included if Resident #1's heart stops, initiate CPR and call 911 for transfer to the hospital. Record review of Resident #1's physician order dated [DATE] indicated Resident #1 was full code-CPR. Record review of the facility's incident report dated [DATE] at 11:10 p.m. (per LVN A the time was an error) completed by LVN A indicated Resident #1 was noted lying face down on the floor. Resident #1 was unresponsive. His name was called and he was rolled on to his back. Code team was initiated and 911 was called. Staff performed resuscitation efforts until paramedics took over. Physician, RP, and DON notified. Resident #1's breathing was noted as noisy, labored, long period of hyperventilation, ([NAME] Stokes Respiration- respiration is a type of breathing disorder characterized by cyclical episodes of apnea and hyperventilation). He was comatose-(unrousable to verbal or physical stimuli). Record review of the progress note dated [DATE] at 2:50 a.m., completed by LVN A indicated LVN A reassessed Resident #1 post fall. Resident #1 was lying on the floor face down. Resident #1 was not breathing. LVN attempted to get BP, pulse ox (electronic device that measures the saturation of oxygen carried in red blood cells). Resident #1 did not respond to his name or sternum rub. Code team was initiated and 911 was called. After several attempts to resuscitate Resident #1, he was pronounced expired by doctor via EMS. Notified physician. Family notified and present in facility. Record review of the EMS run time provided by SW I indicated EMS received an alarm on [DATE] at 11:28 p.m. EMS left the faciity on [DATE] at 12:29 a.m. Record review of the facility's crash cart check of list dated [DATE] and [DATE] indicated there was no AED device listed. During an interview on [DATE] at 10:43 a.m., LVN A said Resident #1 had a fall at approximately 10:45 p.m. on [DATE]. She said the time indicated on the incident report was an approximate time and not the correct time. She said CNA B assisted to get Resident #1 up and into his wheelchair. She said he was yelling and cussing. When she asked him why he did not push the call light for help, Resident #1 got up from his wheelchair and went to the toilet then got clean clothes and went to bed. She said she assessed Resident #1 and all his vital were WNL . She said he did not hit his head and had clear speech. She said she told Resident #1 she would be back in 15 minutes to complete another set of neurological checks. She said she went to administer medications to two other residents and was returning to Resident #1's room at approximately 11:15 p.m. when CNA B indicated Resident #1 was on the floor. She said Resident #1 was face down on the floor and did not respond to his name or to sternum rub. She said he had no pulse and she could not get a pulse. She said she called for the crash cart and directed a CNA (she could not recall which CNA) to call 911. She said she began CPR because Resident #1 was a full code. She said she continued CPR until EMS arrived and took over. She said she did not call for the AED and did not use the AED during CPR for Resident #1. She said she could not recall why she did not call for the AED or use the AED during CPR. She said she had her CPR training and CPR card. She said she should have used the AED and followed the prompts. She said the AED device was used for giving the heart a shock if it was needed. During an interview on [DATE] at 10:55 a.m., the DON said she received a call on [DATE] at 11:38 p.m. from LVN A. LVN A reported Resident #1 was unresponsive and the paramedics were working on him. She said she arrived in the facility on [DATE] at 11:42 p.m. to cover a shift. Observation on [DATE] at 11:05 a.m. revealed the facility's crash cart was adjacent to the nurse station. The check off list did not include AED inspection. Observation of the AED device indicated it was in a red box with a sign hanging on a wall halfway between the nurse's station and the dining room area. There was no inspection or check off list available for review. During an interview on [DATE] at 11:39 a.m., the DON said she asked LVN A why she did not use the AED during CPR for Resident #1 on [DATE]. She said LVN A said she did not know and that she was probably busy with CPR and did not think about the AED. She said LVN A should have called for the AED and the crash cart. She said the AED device was used for giving the heart a shock if it was needed. She said the only AED was located down the hall from where the crash cart was located (by the nurse station). She said she had scheduled training for 2:00 p.m. today ([DATE]) to re-train staff to remember to use the AED during CPR. The DON said there was no separate check off list for the AED device. She said she checked the device daily and replaced the pads when necessary. During an interview on [DATE] at 3:15 p.m., CNA B said on [DATE] at approximately 11:15 p.m., she was passing Resident #1's door and saw he was lying face down on the floor . She said he did not respond when she called his name. She said she called for LVN A as LVN A was coming up the hall and she went immediately into the room. She said she assisted to roll Resident #1 over on to his back. She said LVN A called Resident #1's name and rubbed his chest and Resident #1 did not respond. She said CNA D arrived and was directed to call 911. She said LVN A began CPR. CNA B said she went to get LVN C from another area of the facility. She said LVN C brought the crash cart. She said CNA D returned to the room and said she called 911. She said she did not recall anyone calling for the AED device. She said she did not think or remember to get the AED device. She said she had her CPR card and knew the AED device was should have been implemented during the CPR for Resident #1. She said the AED device was used for giving the heart a shock if it was needed. The surveyor called, left a voicemail, and sent a text to LVN C on [DATE] at 3:46 p.m. for an interview. The surveyor left her contact information. LVN C did not respond. Record review of LVN A's CPR card was issued on [DATE] and valid until ,d+[DATE]. Record review of LVN C's CPR card issued on [DATE] and valid for two years. Record review of the facility's undated Emergency Procedure-Cardiopulmonary Resuscitation indicated Personnel have completed training on the initiation of the cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. 4. The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse, 5. Early delivery of a shock with a defibrillator plus CPR within 3 to 5 minutes of collapse can further increase chances of survival. Record review of the facility's undated Automatic External Defibrillator policy indicated The facility has an automatic external defibrillator (AED) equipment available for emergency use. The Administrator was notified on [DATE] at 3:57 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template and the plan of removal was requested on [DATE] at 4:06 p.m. The facility's Plan of Removal was accepted on [DATE] at 8:14 a.m. and included: Action: Immediately an In-service was conducted with nurses on CPR/ and using AED machine when someone is in cardiac arrest, 100% in-service completion was done by Director of Nursing on [DATE]. Licensed nurses are the only ones to perform CPR and use AED currently at the facility. The Clinical Director of Operations provided the Director Of Nursing (DON) a modified crash cart checklist which included AED machine, DON was in serviced on form to be checked off daily by nurses to ensure AED is operable and ready for usage. Director of Nursing completed services with nurses on [DATE]. AED will be placed with the Crash cart for easy access during CPR. Please review and accept this Plan of Removal. All items above have been completed with completion date and time [DATE], at 8:30 pm. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Observation on [DATE] at 8:45 a.m. revealed the crash cart was located under the AED (located in a red box under a sign) in the hall between the nurse station and the dining room. The daily check sheet was updated with checks to include the AED and checked off by nursing staff. The green indicator light was flashing on the AED. The DON verified that the AED was functioning as intended. Interviews were conducted on [DATE] from 9:00 a.m. through 10:35 a.m. with the Administrator, the DON, LVN E ,d+[DATE], LVN F ,d+[DATE], CNA G ,d+[DATE] and ,d+[DATE], CNA H ,d+[DATE], prn other shifts, CNA J ,d+[DATE], prn other shifts, RNA K ,d+[DATE] Monday-Friday, CMA L ,d+[DATE], prn other shifts, CNA M ,d+[DATE], LVN A ,d+[DATE], and LVN N weekend doubles. They indicated they received an in-service on [DATE] and were aware the AED was supposed to be collected with the crash cart and utilized when staff called for the crash cart/911. They were aware the crash cart was moved from the nurse station and located under the AED on the wall, in the hall between the nurse station and the dining room. The nurses also said that checking the box marked AED meant the AED was above the crash cart and the AED's blinking green indicator light was observed. The nurses said the flashing green indicator light the AED was ready for use. Record review of an in-service dated [DATE] indicated all nursing staff were trained on the CPR policy including the use of AED and daily checks of the crash cart and of the AED to ensure it was working. Record review of the daily check sheet for the crash cart was updated on [DATE] with checks to include the AED. The sheet was checked off on [DATE] by nursing staff. While the IJ was removed on [DATE] at 10:37 a.m., the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure the physician was consulted for a change of condition for 1 of 11 residents (Resident #1) reviewed for notification of changes. The facility did not notify the physician when Resident #1 had a decline of meal intake. This failure could place residents at risk for delay in treatment and decreased quality of life. Findings included: Record review of Resident #1's face sheet dated 03/12/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included degenerative disease of nervous system, dementia the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities, and unspecified protein-calorie malnutrition a nutritional status in which reduced availability of nutrients leads to changes in body composition and function. Record review of Resident #1's MDS dated [DATE] indicated she was able to make herself understood, sometimes understood others, had severe cognitive impairment (BIMS score of 4), used a wheelchair for mobility, required set up or clean up assistance prior to or following eating, and required substantial/maximal assistance for most ADLS. Record review of Resident #1's care plan dated 04/18/23 indicated Resident #1 was at risk for weight loss. Interventions included serve diet as ordered and offer subs when less than 50% of meal was eaten. Record review of Resident #1's weight records indicated: *02/08/24 130.1 lbs. *01/17/24 129.6 lbs. *01/10/24 125.4 lbs. Record review of Resident #1's meal intake records dated indicated: *02/29/24 0-25 % for 2 of 3 meals *02/28/24 0-25% for 2 of 3 meals, refused 1 of 3 meals *02/27/24 0-25 % for 1 of 3 meals, 26-50% for 1 of 3 meals, and refused 1 of three meals *02/26/24 0-25 % for 1 of three meals, 26-50% for 2 of three meals Record review of Resident #1's substitutions offered dated 02/26/24 through 02/29/24 indicated all refused. Record review of Resident #1's physician order dated 03/12/24 indicated Resident #1's dietary order as regular diet, regular texture/thin liquids, fortified foods, and magic cup with lunch and dinner. Record review of Resident #1's progress notes dated 02/26/24 through 02/29/24 indicated there was no documentation of Resident #1's meal refusals. Record review of Resident #1's hospital records dated 02/29/24 indicated Resident #1 presented with productive cough, shortness of breath, altered mental status, generalized weakness malaise, and some seizures fevers. Resident #1 had decreased appetite and worsening confusion over last 24 hours. Resident #1's Pulse Ox was 91%, she was in emotional distress, obviously demented, delirious, and agitated. Her eyes were sunken in. She was given a liter of fluid for hydration, and Rocephin (antibiotic) via IV, nebulizer treatments for wheezing, and supplemental oxygen. Resident #1 was dehydrated with acute renal failure, pneumonia, and a UTI. Hospital records further indicated: Please note that critical care services that were medically necessary and reasonable were provided by me for approximately just over 30-60 minutes excluding intubation procedures I believe that the failure to initiate my given interventions on an emergent basis would likely result in sudden clinical significant or life-threatening deterioration in the patient's condition. Record review of Resident #1's hospital lab records dated 02/29/24 indicated -BUN 68-High-Reference Range 10-20 mg/dL -Creatinine 2.0-High-Reference Range 0.6-1.1 mg/dL -Est GFR 25-Low-Reference Range 50-100 (stage 4 kidney disease) -Glucose 119-High-Reference Range 60-100 mg/dL Resident #1 was discharged to hospital on 02/29/24 and not available for interview during the investigation. During an interview on 03/27/24 at 11:23 a.m., LVN A said she was not aware Resident #1's meal intake had declined for 3 days prior to her family member demanding Resident #1 be sent out to hospital. She said the staff should have reported Resident #1 had not eaten her meals or refused her meals. She said Resident #1 did not usually eat more than 50% of her meals. She said she would have reported the decline to the DON and the physician. During an interview on 03/27/24 at 11:56 a.m., NP C said he was not aware of Resident #1's meal refusals. He said he may have ordered an appetite stimulant for Resident #1. He said Resident #1 could have a significant decline and nutritional deficiencies without adequate nutrition. During an interview on 03/27/24 at 2:33 p.m., CNA B said Resident #1 usually ate less than 25% or less than 50% of her meals. She said Resident #1 was able to feed herself. She said she was supposed to notify the nurse if Resident #1 refused her meals. She said she could not recall if she notified the nurse. During an interview on 03/27/24 at 12:56 p.m., the DON said the staff should have informed the nurse if Resident #1 refused her meals. She said it was her expectation staff would notify the physician if a resident had a decline and refused meals. She said residents were at risk of decline in health and not receiving medical interventions if the physician was not notified of resident change of condition or decline. The surveyor contacted RD E on 03/27/24 at 1:17 p.m. for an interview. There was no answer. The surveyor left contact information. RD E did not respond. MD D was out of the country and not available for interview. Record review of the facility's undated Change in a Resident's Condition or Status policy indicated Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the residence medical/mental condition and/or status . 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an) . d. significant change in the resident's physical/emotional/mental condition; . 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standards disease-related clinical interventions(is not self-limiting) .

Based on interview and record review the facility failed to obtain laboratory services ordered by physician for 1 of 11 residents (Resident #1) reviewed for labs. The facility did not obtain labs- CBC (complete blood count- used to measure different parts and features of blood), CMP (Complete Metabolic Panel-test used to monitor the blood sugar levels, the balance of electrolytes and fluid as well as the health of kidneys and liver), lipid (levels of cholesterol and other fats in the blood), A1C (blood test that measures average blood sugar levels over the past 3 months), thyroid (blood tests used to measure how well the thyroid gland is working), vitamin B12 and vitamin D hydroxy 25 as ordered by NP C on 02/23/24. This failure could place residents at risk of a delay in treatment. The findings were: Record review of Resident #1's face sheet dated 03/12/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnosis included degenerative disease of nervous system, dementia the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities, and unspecified protein-calorie malnutrition a nutritional status in which reduced availability of nutrients leads to changes in body composition and function. Record review of Resident #1's MDS dated [DATE] indicated she was able to make herself understood, sometimes understood others, had severe cognitive impairment (BIMS score of 4), used a wheelchair for mobility, required set up or clean up assistance prior to or following eating, and required substantial/maximal assistance for most ADLS. Record review of Resident #1's physician orders (provided as evidence by NP C in a text message with a photo) dated 02/23/24 indicated NP C ordered CBC, CMP, lipid, A1C, thyroid, vitamin B12, and vitamin D hydroxy 25. Record review of Resident #1's EMR indicated there were no lab results indicating the labs had been drawn in the facility since the 02/23/24's physician's order. Resident #1 was discharged to hospital on 02/29/24 and not available for interview during the investigation. Record review of Resident #1's hospital records dated 02/29/24 indicated Resident #1 presented with productive cough, shortness of breath, altered mental status, generalized weakness malaise, and some seizures fevers. Resident #1 had decreased appetite and worsening confusion over last 24 hours. Resident #1's Pulse Ox was 91%, she was in emotional distress, obviously demented, delirious, and agitated. Her eyes were sunken in. She was given a liter of fluid for hydration, and Rocephin (antibiotic) via IV, nebulizer treatments for wheezing, and supplemental oxygen. Resident #1 was dehydrated with acute renal failure, pneumonia, and a UTI. Hospital records further indicated: Please note that critical care services that were medically necessary and reasonable were provided by me for approximately just over 30-60 minutes excluding intubation procedures I believe that the failure to initiate my given interventions on an emergent basis would likely result in sudden clinical significant or life-threatening deterioration in the patient's condition. Record review of Resident #1's hospital lab records dated 02/29/24 indicated -BUN 68-High-Reference Range 10-20 mg/dL -Creatinine 2.0-High-Reference Range 0.6-1.1 mg/dL -Est GFR 25-Low-Reference Range 50-100 (stage 4 kidney disease) -Glucose 119-High-Reference Range 60-100 mg/dL During an interview on 03/27/24 at 11:56 a.m., NP C said he ordered Resident #1's labs for CBC , CMP, lipid, A1C, thyroid (blood tests used to measure how well the thyroid gland is working), vitamin B12, and vitamin D hydroxy 25 on 02/23/24 for a 6 month follow up to her (Resident #1) previous labs. He said he left the written orders at nurse station #1. He could not recall the nurse he gave the orders to. He said he was not able to locate the results to review. He said the lab results could indicate a need for treatment and not obtaining labs as ordered could place the resident at risk of health complications. During an interview on 03/27/24 at 2:19 p.m., the DON said NP C's orders for Resident #1's labs written on 02/23/24 were not transcribed or entered into the portal. She said labs that were ordered on 02/23/24 would have been drawn on 02/26/24. She said she was not able to locate NP C's written orders. She said the orders were left at nurse station #1 and Resident #1's information was at nurse station #2. The DON said the risk of not doing labs if elevated or low results could be a potential problem and not get reported to the physician timely. The DON stated the nurse writing or receiving the order should follow through to completion to ensure the orders were entered in the electronic portal. Record review of the facility's undated Lab and Diagnostic Test Results-Clinical Protocol indicated . 2. The staff will process test requisitions and arrange for tests.

Based on interview and record review, the facility failed to ensure that Resident #1 received treatment and care in accordance with professional standards of practice for 1 of 11 resident (Resident #1) reviewed quality of care. The facility did not notify the physician when Resident #1 had a decline of meal intake. The facility did not obtain labs- CBC (complete blood count- used to measure different parts and features of blood), CMP (Complete Metabolic Panel-test used to monitor the blood sugar levels, the balance of electrolytes and fluid as well as the health of kidneys and liver), lipid (levels of cholesterol and other fats in the blood), A1C (blood test that measures average blood sugar levels over the past 3 months), thyroid (blood tests used to measure how well the thyroid gland is working), vitamin B12 and vitamin D hydroxy 25 as ordered by NP C on 02/23/24. These failures placed residents at risk of not receiving adequate care and medical interventions to maintain their health and prevent worsening health conditions. Findings included: Record review of Resident #1's face sheet dated 03/12/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included degenerative disease of nervous system, dementia the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities, and unspecified protein-calorie malnutrition a nutritional status in which reduced availability of nutrients leads to changes in body composition and function. Record review of Resident #1's MDS dated [DATE] indicated she was able to make herself understood, sometimes understood others, had severe cognitive impairment (BIMS score of 4), used a wheelchair for mobility, required set up or clean up assistance prior to or following eating, and required substantial/maximal assistance for most ADLS. Record review of Resident #1's care plan dated 04/18/23 indicated Resident #1 was at risk for weight loss. Interventions included serve diet as ordered and offer subs when less than 50% of meal was eaten. Record review of Resident #1's weight records indicated: *02/08/24 130.1 lbs. *01/17/24 129.6 lbs. *01/10/24 125.4 lbs. Record review of Resident #1's meal intake records dated indicated: *02/29/24 0-25 % for 2 of 3 meals *02/28/24 0-25% for 2 of 3 meals, refused 1 of 3 meals *02/27/24 0-25 % for 1 of 3 meals, 26-50% for 1 of 3 meals, and refused 1 of three meals *02/26/24 0-25 % for 1 of three meals, 26-50% for 2 of three meals Record review of Resident #1's substitutions offered dated 02/26/24 through 02/29/24 indicated all refused. Record review of Resident #1's physician order dated 03/12/24 indicated Resident #1's dietary order as regular diet, regular texture/thin liquids, fortified foods, and magic cup with lunch and dinner. Record review of Resident #1's progress notes dated 02/26/24 through 02/29/24 indicated there was no documentation of Resident #1's meal refusals. Record review of Resident #1's hospital records dated 02/29/24 indicated Resident #1 presented with productive cough, shortness of breath, altered mental status, generalized weakness malaise, and some seizures fevers. Resident #1 had decreased appetite and worsening confusion over last 24 hours. Resident #1's Pulse Ox was 91%, she was in emotional distress, obviously demented, delirious, and agitated. Her eyes were sunken in. She was given a liter of fluid for hydration, and Rocephin (antibiotic) via IV, nebulizer treatments for wheezing, and supplemental oxygen. Resident #1 was dehydrated with acute renal failure, pneumonia, and a UTI. Hospital records further indicated: Please note that critical care services that were medically necessary and reasonable were provided by me for approximately just over 30-60 minutes excluding intubation procedures I believe that the failure to initiate my given interventions on an emergent basis would likely result in sudden clinical significant or life-threatening deterioration in the patient's condition. Resident #1 was discharged to hospital on 02/29/24 and not available for interview during the investigation. Record review of Resident #1's physician orders (provided as evidence by NP C in a text message with a photo) dated 02/23/24 indicated NP C ordered CBC, CMP, lipid, A1C, thyroid, vitamin B12, and vitamin D hydroxy 25. Record review of Resident #1's EMR indicated there were no lab results indicating the labs had been drawn in the facility since the 02/23/24's physician's order. Record review of Resident #1's hospital lab records dated 02/29/24 indicated -BUN 68-High-Reference Range 10-20 mg/dL -Creatinine 2.0-High-Reference Range 0.6-1.1 mg/dL -Est GFR 25-Low-Reference Range 50-100 (stage 4 kidney disease) -Glucose 119-High-Reference Range 60-100 mg/dL During an interview on 03/27/24 at 11:23 a.m., LVN A said she was not aware Resident #1's meal intake had declined for 3 days prior to her family member demanding Resident #1 be sent out to hospital. She said the staff should have reported Resident #1 had not eaten her meals or refused her meals. She said Resident #1 did not usually eat more than 50% of her meals. She said she would have reported the decline to the DON and the physician. During an interview on 03/27/24 at 11:56 a.m., NP C said he was not aware of Resident #1's meal refusals. He said he may have ordered an appetite stimulant for Resident #1. He said Resident #1 could have a significant decline and nutritional deficiencies without adequate nutrition. NP C said he ordered Resident #1's labs for CBC , CMP, lipid, A1C, thyroid (blood tests used to measure how well the thyroid gland is working), vitamin B12, and vitamin D hydroxy 25 on 02/23/24 for a 6 month follow up to her (Resident #1) previous labs. He said he left the written orders at nurse station #1. He could not recall the nurse he gave the orders to. He said he was not able to locate the results to review. He said the lab results could indicate a need for treatment and not obtaining labs as ordered could place the resident at risk of health complications. During an interview on 03/27/24 at 2:33 p.m., CNA B said Resident #1 usually ate less than 25% or less than 50% of her meals. She said Resident #1 was able to feed herself. She said she was supposed to notify the nurse if Resident #1 refused her meals. She said she could not recall if she notified the nurse. During an interview on 03/27/24 at 12:56 p.m., the DON said the staff should have informed the nurse if Resident #1 refused her meals. She said it was her expectation staff would notify the physician if a resident had a decline and refused meals. She said residents were at risk of decline in health and not receiving medical interventions if the physician was not notified of resident change of condition or decline. The surveyor contacted RD E on 03/27/24 at 1:17 p.m. for an interview. There was no answer. The surveyor left contact information. RD E did not respond. During an interview on 03/27/24 at 2:19 p.m., the DON said NP C's orders for Resident #1's labs written on 02/23/24 were not transcribed or entered into the portal. She said labs that were ordered on 02/23/24 would have been drawn on 02/26/24. She said she was not able to locate NP C's written orders. She said the orders were left at nurse station #1 and Resident #1's information was at nurse station #2. The DON said the risk of not doing labs if elevated or low results could be a potential problem and not get reported to the physician timely. The DON stated the nurse writing or receiving the order should follow through to completion to ensure the orders were entered in the electronic portal. MD D was out of the country and not available for interview. Record review of the facility's undated Change in a Resident's Condition or Status policy indicated Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the residence medical/mental condition and/or status . 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an) . d. significant change in the resident's physical/emotional/mental condition; . 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standards disease-related clinical interventions(is not self-limiting) . Record review of the facility's undated Lab and Diagnostic Test Results-Clinical Protocol indicated . 2. The staff will process test requisitions and arrange for tests.

Based on interview and record review, the facility failed to immediately consult with the resident's physician of lab results and treatment recommendations for 1 of 8 residents (Resident #1) reviewed for change of condition. The facility did not notify Resident #1's wound care doctor or primary physician of recommendations dated 11/16/22 for antibiotics for possible wound infection of the right foot and a CT or MRI to rule out (osteomyelitis inflammation or swelling that occurs in the bone). Resident #1 had a partial resection of the 5th metatarsal of the right foot and wound and muscle debridement of the left trans-metatarsal stump on 12/15/22. The facility did not notify or consult Resident #1's physician of stat lab dated 11/22/22 results positive for MRSA. An Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving immediate corrective actions necessary for their health and that could cause, or likely continue to cause, serious injury, harm, impairment or death. Findings included: Record review of physician orders dated 01/03/2022 indicated Resident #1 was a [AGE] year-old male readmitted on [DATE] (originally admitted on [DATE]). His diagnoses included long term use of antibiotics, acute osteomyelitis (inflammation or swelling that occurs in the bone) right ankle and foot, diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high , cellulitis bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin, gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection), non-pressure chronic ulcer of left foot, cellulitis of left lower limb and acute osteomyelitis of left foot and ankle. Record review of an MDS dated [DATE] indicated Resident #1 had moderate impaired cognition, was understood by others and usually understood others. He was not able to focus and had disorganized thinking. He had delusions. He required supervision for most ADLS. He utilized a wheelchair for mobility. He was continent of bladder and bowel. Resident #1 had surgical wounds and received surgical wound care. There was no antibiotic use noted. Record review of a care plan dated 11/09/22 indicated Resident #1 had right foot amputation of small toe and was at risk of further skin breakdown, infection, and worsening surgical wound. Interventions included inform MD of progress and perform treatment per order and if no improvement report to MD. Record review of a care plan dated 11/09/2022 indicated Resident #1 had a left foot amputation of toes and was at risk for further skin breakdown, infection and worsening surgical wound. Interventions included inform MD of progress and perform treatment per order and if no improvement report to MD. Record review of a wound evaluation dated 11/16/22, completed by RN B, indicated Resident #1's right lateral toe's surgical wound measured 3.5 cm X 2.0 cm X .3 cm, 25 % slough (necrotic tissue that needs to be removed from the wound), and moderate serous exudate (type of exudate that is clear, thin, and watery in contrast to a purulent exudate that is opaque). There was purulent (discharging) pus present and RN B recommended ABT (Bactrim, Doxycycline) and a CT or MRI to rule out osteomyelitis (inflammation or swelling that occurs in the bone). Record review of Resident #1's clinical record indicated there was no progress note or treatment note available for review from the wound care consult on 11/16/22. Record review of progress note dated 11/21/22 at 12:08 p.m., completed by RN N (previous DON) indicated Resident #1 complained he had drainage to bilateral feet. Scant amount of clear drainage noted with no signs of infection. MD A's office was called and there was no answer and would follow-up. Record review of progress note dated 11/21/22 at 4:57 p.m., completed by ADON D, indicated she contacted MD A's office and received order for wound culture of wounds to bilateral feet. Antibiotic to be ordered once results were received. Record review of STAT lab results dated 11/22/22 indicated Resident #1 was positive for methicillin-resistant Staphylococcus aureus (MRSA) - (staph infection that is difficult to treat because of resistance to some antibiotics). Record review of wound care report dated 12/13/22, competed by DPM C indicated Resident #1 was admitted to hospital for infection of right foot. Record review of a history and physical report (included with the hospital records) dated 12/14/22 indicated Resident #1 had osteomyelitis with gangrene at right metatarsal site. Record review of consult report (included with the hospital records) dated 12/15/22 indicated Resident #1 had a partial resection of the 5th metatarsal of the right foot and wound and muscle debridement of the left trans-metatarsal stump. The wound cultures were growing MRSA. Resident #1 returned to the facility on [DATE]. During an observation and interview on 12/30/23 at 10:50 a.m., Resident #1 was wearing a protective foot device on his right and left foot. He said he had a staph infection on his foot and was in the hospital and received intravenous antibiotics. He said he had to have more amputations because he did not get the antibiotics he was supposed to get. He could not recall who said he should have antibiotics. During an interview on 01/04/23 at 10:07 a.m., TX LVN E said she made wound rounds with RN B (wound care consultant) on 11/16/22. She said it was toward the end of her shift and she asked a nurse to fax the wound care consult with recommendations to Resident #1's wound care doctor (DPM C) and to follow up because she was not returning to the facility. She said 11/16/22 was the last day she worked in the facility. She said she could not recall the name of the nurse she gave the recommendations or directions to notify the physician. She said she did not notify Resident #1's primary physician or DPM C. She said she could not recall if she documented the recommendations in a progress note. During an interview on 01/04/23 at 1:40 p.m., LVN F said she worked on 11/16/22 and did not recall TX LVN E giving her a wound care recommendation for Resident #1 or being directed to fax it to DPM C. During an interview on 01/04/23 at 2:00 p.m., ADON H said she worked on 11/16/22 and did not recall TX LVN E giving her a wound care recommendation for Resident #1 or being directed to fax it to DPM C. During an interview on 01/4/23 at 3:26 p.m., RN L (from the wound care clinic) said they did not have any knowledge and were not informed of RN B's recommendations dated 11/16/22 for Resident #1 that included ABT (Bactrim, Doxycycline) and a CT or MRI to rule out osteomyelitis. During an interview on 01/04/23 at 5:10 p.m., RN B said she was a wound care consultant and was contracted by the facility to observe wound care and train the staff. She said she completed rounds with TX LVN E on 11/16/22 and noted purulent pus and made recommendation for ABT and CT or MRI to rule out osteomyelitis. She said TX LVN E should have informed the primary physician of the assessment and recommendations. She said some primary physicians would direct the facility to forward the recommendations to the wound care physician. She said infection of the wound could get to the blood or get septic (infected with microorganisms, especially harmful bacteria). During an interview on 01/05/23 at 9:43 a.m., ADON D said she did get the order for Resident #1's wound culture on 11/21/22. She said she was new to the position and should probably have followed up on the results. She said she was off sick and then forgot to follow up when she returned to work. During an interview on 01/05/23 at 10:54 a.m., MD A said he did not receive notification of Resident #1's wound culture results dated 11/22/22 regarding positive MRSA results. He said the facility staff should have notified him of RN B's recommendations dated 11/16/22 for Residents #1. He said the delay of notification, treatment, or ABT most likely would not have made any difference because Resident #1 had been on multiple [NAME] and was ABT resistant. He said Resident #1 was non-compliant with wound care and physician orders. MD A said it was also most likely to require additional surgeries and amputations. During an interview on 01/05/23 at 12:06 p.m., ADON H said if they received recommendations from consultants, they would contact the physician. ADON D said lab results were supposed to be called or faxed over to the physician for review. ADON H said the lab results should be noted in the progress notes and also in the 24-hour report. During an interview on 01/05/23 at 12:27 p.m., LVN J said all recommendations for care, tests, or treatments were supposed to be sent to the physician for review. LVN M said lab results were supposed to be called or faxed over to the physician for review. LVN M They said the lab results are supposed to be noted in the progress notes and also in the 24-hour report. During an interview on 01/05/23 at 8:25 a.m., the DON said Resident #1's lab results were not forwarded to MD A. She said the lab results should have been followed up by nursing staff to ensure Resident #1 received treatment. She said the results were in the facility electronic portal but not all staff had access to the portal. She said not informing the physician of recommendations or lab results could result in delay of treatment or further decline of condition. She said she could not attribute the delay of antibiotics to Resident #1 requiring additional amputation surgery because he was noncompliant with care and treatment. She said staff were in-serviced on 12/29/22 to ensure labs were documented and followed up as required. During an interview on 01/05/23 at 8:30 a.m., LD I said Resident #1's lab results were available in the portal. He said the lab results were also faxed to the facility. He said he was not able to say who had access to the portal or who reviewed the labs. The surveyors made three attempts on 01/03/23 and three attempts on 01/04/22 were made to contact DPM C regarding Resident #1 and there was no return call. Record review of the facility's undated Laboratory Services and Reporting policy indicated .7. Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. Record review of the facility policy Change in Condition Communication dated 06/19 indicated physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patients/ residence condition, enter. Provide guidance for the notification of patients/ residents and their responsible party regarding changes in condition. F. Recent Labs The Administrator and the DON were notified an Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. The facility's POR dated 01/26/23 indicated: DON and CNO reviewed 24-hour report for the last 24 hours. Changes in condition noted on the 24-hour report were addressed and documented. On 1.25.23 CNO re-educated facility nurses including nurse managers regarding: Documentation on resident's change(s) in condition to include completion of SBAR assessment when notifying MD and documenting on 24-hour report. During shift nurses were educated and those not scheduled to work will be in-serviced prior to their next scheduled shift. Completion Date 1.26.23 @ 12 pm. ADON/Designee will pull 24-hour report and 24-hour lookback and SBARS for completion of MD notification and that orders were followed through. ADONs will bring 24-hour report book and SBAR to clinical morning meeting to discuss follow-up if needed. DON/Designee will audit 24-hour report and SBARS weekly on Wednesdays looking for MD notification and that orders were carried out and acted upon. On 01/26/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of staff training dated 01/25/23 indicated all nursing staff were trained in person or by phone to notify the physician via phone call of lab results and document in the electronic records. If there was no response the nursing staff would notify the Medical Director. If there was no answer nursing staff would send the resident to the hospital if it was a critical lab result. Record review of new hire education indicated the DON incorporated physician notification and the facility policy as part of the onboarding education as of 01/26/23. Record review of the facility monitoring sheets indicated the Administrator would verify the education was done for new hires starting 01/26/23. There were no new hires as of 01/26/23. Record review of the monitoring sheets indicated the Administrator reviewed at the morning meetings on 01/26/23 to verify that a change in condition requiring physician notification was done, physician orders, a follow up if physician deemed it necessary and the order was followed through for 3 residents. Record review dated 01/25/23 indicated the Administrator was educated by Corporate Nurse on how review change of condition at morning meetings. During an interview on 01/26/23 at 2:20 p.m., the Administrator was able to verbalize the monitoring for change of condition procedures. She said the DON and the ADON were designees if she was not able to complete the monitoring during morning meeting. Record review of the facility's chart audit dated 01/25/23 indicated the facility had completed 100% chart audit and notified the physicians of any changes as required. Interviews conducted on 01/26/23 from 1:15 p.m. through 2:30 p.m. with the DON, the 2 ADONs, 1 RN, and 6 LVNS, who worked all shifts, indicated they were able to correctly state the protocols for notification of the physician when there was a change of condition or a need to alter treatment for a resident, reviewing and reporting abnormal labs, clarification of verbal orders, ensuring the physician was made aware of the change or condition, and ensuring the physician received the lab results. An Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. 33460

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and resident choices for 1 of 8 residents (Resident #1) reviewed for treatment and services. The facility failed implement interventions and recommendations for Resident #1 dated 11/16/22 for antibiotics for possible wound infection of the right foot and a CT or MRI to rule out (osteomyelitis inflammation or swelling that occurs in the bone). Resident #1 he was admitted to the hospital on 12/13/22 had a partial resection of the 5th metatarsal of the right foot and wound and muscle debridement of the left trans-metatarsal stump. The facility failed to address Resident #1's stat lab dated 11/22/22 results positive for MRSA. An Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving care as required and could result in further decline of condition and possible death. Findings included: Record review of physician orders dated 01/03/2022 indicated Resident #1 was a [AGE] year-old male readmitted on [DATE] (originally admitted on [DATE]). His diagnoses included long term use of antibiotics, acute osteomyelitis (inflammation or swelling that occurs in the bone) right ankle and foot, diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high , cellulitis bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin, gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection), non-pressure chronic ulcer of left foot, cellulitis of left lower limb and acute osteomyelitis of left foot and ankle. Record review of an MDS dated [DATE] indicated Resident #1 had moderate impaired cognition, was understood by others and usually understood others. He was not able to focus and had disorganized thinking. He had delusions. He required supervision for most ADLS. He utilized a wheelchair for mobility. He was continent of bladder and bowel. Resident #1 had surgical wounds and received surgical wound care. There was no antibiotic use noted. Record review of a care plan dated 11/09/22 indicated Resident #1 had a left foot amputation of toes and right foot amputation of small toe and was at risk of further skin breakdown, infection, and worsening surgical wound. Interventions included inform MD of progress and perform treatment per order and if no improvement report to MD. Record review of a wound evaluation dated 11/16/22, completed by RN B (wound consultant), indicated Resident #1's right lateral toe's surgical wound measured 3.5 cm X 2.0 cm X .3 cm, 25 % slough (necrotic tissue that needs to be removed from the wound), and moderate serous exudate (type of exudate that is clear, thin, and watery in contrast to a purulent exudate that is opaque). There was purulent (discharging) pus present and RN B recommended ABT (Bactrim, Doxycycline) and a CT or MRI to rule out osteomyelitis (inflammation or swelling that occurs in the bone). Review of Resident #1's clinical records indicated there was no progress note or treatment note available for review from the wound care consult on 11/16/22. Record review of progress note dated 11/21/22 at 12:08 p.m., completed by RN N (previous DON) indicated Resident #1 complained he had drainage to bilateral feet. Scant amount of clear drainage noted with no signs of infection. MD A's office was called and there was no answer and would follow-up. Record review of progress note dated 11/21/22 at 4:57 p.m., completed by ADON D, indicated she contacted MD A's office and received order for wound culture of wounds to bilateral feet. Antibiotic to be ordered once results were received. Record review of STAT lab results dated 11/22/22 indicated Resident #1 was positive for methicillin-resistant Staphylococcus aureus (MRSA) - (staph infection that is difficult to treat because of resistance to some antibiotics). There was no documented evidence the results were reviewed by the physician or NP. Record review of wound care report dated 12/13/22, competed by DPM C indicated Resident #1 was admitted to hospital for infection of right foot. Record review of a history and physical report (included with the hospital records) dated 12/14/22 indicated Resident #1 had osteomyelitis with gangrene at right metatarsal site. Record review of consult report (included with the hospital records) dated 12/15/22 indicated Resident #1 had a partial resection of the 5th metatarsal of the right foot and wound and muscle debridement of the left trans-metatarsal stump. The wound cultures were growing MRSA. Resident #1 returned to the facility on [DATE]. During an observation and interview on 12/30/23 at 10:50 a.m., Resident #1 was wearing a protective foot device on his right and left foot. He said he had a staph infection on his foot and was in the hospital and received intravenous antibiotics. He said he had to have more amputations because he did not get the antibiotics he was supposed to get. He could not recall who said he should have antibiotics. During an interview on 01/04/23 at 10:07 a.m., TX LVN E said she made wound rounds with RN B (wound care consultant) on 11/16/22. She said it was toward the end of her shift and she asked a nurse to fax the wound care consult with recommendations to Resident #1's wound care doctor (DPM C) and to follow up because she was not returning to the facility. She said 11/16/22 was the last day she worked in the facility. She said she could not recall the name of the nurse she gave the recommendations or directions to notify the physician. She said she did not notify Resident #1's primary physician or DPM C. She said she could not recall if she documented the recommendations in a progress note. During an interview on 01/04/23 at 1:40 p.m., LVN F said she worked on 11/16/22 and did not recall TX LVN E giving her a wound care recommendation for Resident #1 or being directed to fax it to DPM C. During an interview on 01/04/23 at 2:00 p.m., ADON H said she worked on 11/16/22 and did not recall TX LVN E giving her a wound care recommendation for Resident #1 or being directed to fax it to DPM C. During an interview on 01/4/23 at 3:26 p.m., RN L (from the wound care clinic) said they did not have any knowledge and were not informed of RN B's recommendations dated 11/16/22 for Resident #1 that included ABT (Bactrim, Doxycycline) and a CT or MRI to rule out osteomyelitis. During an interview on 01/04/23 at 5:10 p.m., RN B said she was a wound care consultant and was contracted by the facility to observe wound care and train the staff. She said she completed rounds with TX LVN E on 11/16/22 and noted purulent pus and made recommendation for ABT and CT or MRI to rule out osteomyelitis. She said TX LVN E should have informed the primary physician of the assessment and recommendations. She said some primary physicians would direct the facility to forward the recommendations to the wound care physician. She said infection of the wound could get to the blood or get septic (infected with microorganisms, especially harmful bacteria). During an interview on 01/05/23 at 9:43 a.m., ADON D said she did get the order for Resident #1's wound culture on 11/21/22. She said she was new to the position and should probably have followed up on the results. She said she was off sick and then forgot to follow up when she returned to work. During an interview on 01/05/23 at 10:54 a.m., MD A said he did not receive notification of Resident #1's wound culture results dated 11/22/22 regarding positive MRSA results. He said the facility staff should have notified him of RN B's recommendations dated 11/16/22 for Residents #1. He said the delay of notification, treatment, or ABT most likely would not have made any difference because Resident #1 had been on multiple [NAME] and was ABT resistant. He said Resident #1 was non-compliant with wound care and physician orders. MD A said it was also most likely to require additional surgeries and amputations. During an interview on 01/05/23 at 12:06 p.m., ADON H said if they received recommendations from consultants, they would contact the physician. ADON D said lab results were supposed to be called or faxed over to the physician for review. ADON H said the lab results should be noted in the progress notes and also in the 24-hour report. During an interview on 01/05/23 at 12:27 p.m., LVN J said all recommendations for care, tests, or treatments were supposed to be sent to the physician for review. LVN M said lab results were supposed to be called or faxed over to the physician for review. LVN M They said the lab results are supposed to be noted in the progress notes and also in the 24-hour report. During an interview on 01/05/23 at 8:25 a.m., the DON said Resident #1's lab results were not forwarded to MD A. She said the lab results should have been followed up by nursing staff to ensure Resident #1 received treatment. She said the results were in the facility electronic portal but not all staff had access to the portal. She said not informing the physician of recommendations or lab results could result in delay of treatment or further decline of condition. She said she could not attribute the delay of antibiotics to Resident #1 requiring additional amputation surgery because he was noncompliant with care and treatment. She said staff were in-serviced on 12/29/22 to ensure labs were documented and followed up as required. During an interview on 01/05/23 at 8:30 a.m., LD I said Resident #1's lab results were available in the portal. He said the lab results were also faxed to the facility. He said he was not able to say who had access to the portal or who reviewed the labs. The surveyors made three attempts on 01/03/23 and three attempts on 01/04/22 were made to contact DPM C regarding Resident #1 and there was no return call. Record review of the facility's undated Laboratory Services and Reporting policy indicated .7. Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. Record review of the facility policy Change in Condition Communication dated 06/19 indicated physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patients/ residence condition, enter. Provide guidance for the notification of patients/ residents and their responsible party regarding changes in condition. F. Recent Labs An Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. The facility's POR indicated: CNO and DON reviewed recommendations from Wound Care Consultant's last visit. Recommendations were addressed with Primary Care Physician and followed through. Nurses at the facility including nursing supervisors were re-educated on 1/25/2023 by CNO that: When a recommendation is made to ask the physician for a decision on the recommendation and follow it through. During shift nurses were educated and those not scheduled to work will be in-serviced prior to their next scheduled shift. Completion Date 1.26.23 @ 12 pm. DON will incorporate this education as part of the onboarding education for any newly hired nurses. Dietary, Wound Care, and Pharmacy Consultants will email recommendations to DON/Administrator once visit is complete. DON will forward recommendations to assigned ADON/Designee for MD notification to obtain approval/denial of recommendation. DON/Designee will audit recommendation(s) on day 4, for completion to include MD notification and that orders were carried out and acted upon. On 01/26/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Review of recommendations from Wound Care Consultant's last visit were addressed with Primary Care Physician and followed through as of 01/26/23. Review of nurse training and nursing supervisors indicated they were re-educated on 01/25/23 by the CNO to ask the physician for a decision on recommendations and follow it through. All nurses were educated as of 01/26/23 and those not scheduled to work would be in-serviced prior to their next scheduled shift. The DON will incorporate this education as part of the onboarding education for any newly hired nurses. As of 01/26/23 there were no untrained new hires. Review of email notification sent to contracted consultants including dietary, wound care, and pharmacy, indicated they would ensure their recommendations were emailed to the DON and Administrator once they have completed their assessments. During an interview on 01/26/23 at 2:30 p.m., the DON said she would forward all recommendations to assigned ADON/Designee for MD notification to obtain approval/denial of recommendation. She said she or the Designee would audit recommendation(s) on day 4, for completion to include MD notification and orders were followed. Interviews conducted on 01/26/23 from 1:15 p.m. through 2:40 p.m. with the DON, 2 ADONs, 1 RN, and 6 LVNS, who worked all shifts, indicated they would document all recommendations in resident clinical record, shift report, and 24-hour report for follow-up and implementation of orders. They were able to correctly state the protocols for reviewing and reporting abnormal labs, clarification of verbal orders, ensuring the physician was made aware of the change or condition, and ensuring the physician received the lab results. An Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to immediately consult the physician with a significant change in resident physical status (that is a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 11 residents (CR #1) reviewed for abnormal labs. The facility failed to notify MD M and did not clearly convey CR #1's abnormal lab results on [DATE] to NP L to obtain treatment interventions. CR#1 was found unresponsive on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 5:30 p.m. While the IJ was removed on [DATE] at 4:46 p.m., the facility remained out of compliance at a scope of isolated and actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for delay of appropriate medical treatment and a worsening of a resident's condition, including death. Findings included: Record review of a face sheet dated [DATE] indicated CR#1 was a [AGE] year-old male resident admitted to the facility on [DATE]. CR#1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR#1's MDS assessment dated [DATE] indicated CR#1 usually made self understood, usually understoods others, had moderate impaired cognitive skills (made poor decisions; cues/supervision required), required extensive physical assist for ADLS, utilized a wheelchair for mobility, had an indwelling catheter, and was incontinent of bowel. Record review of CR#1's baseline care plan dated [DATE] indicated CR#1 was on antibiotic therapy. Review of CR#1's physician's order dated [DATE] indicated CR#1 received [MEDICATION(S)] (used to treat infections, including pneumonia, and infections of the skin. works by stopping the growth of bacteria) tablet 600 mg every 12 hours for infection. Record review of physician order summary dated [DATE] indicated there were no written orders for CR#1 regarding IV fluids or PO fluids. There was no comprehensive care plan for review as it was pending completion. Record review of CR#1's progress notes dated [DATE] at 12:15 a.m., completed by LVN J indicated CR#1's BP was ,d+[DATE], respiratory rate was 74 beats per minute, and O2 saturation was 100% on room air. LVN J notified NP L and received new orders to send to ER. LVN J called 911 at 12:35 a.m. The RP was called, there was no answer, and a message was left to call facility. At 12:50 a.m. EMS arrived and CR#1 was transported to the hospital at 12:55 a.m. Record review of progress note dated [DATE] at 1:48 a.m., completed by LVN J indicated the hospital reported CR#1 was alert, talking and discharged back to the facility on [DATE]. Record review of hospital records dated [DATE] indicated CR#1's BP was assessed numerous times and within normal limits. Record review of progress note completed on [DATE] 3:45 a.m., completed by LVN J indicated CR#1 returned to the facility with no new orders. Record review of progress note dated [DATE] at 1:25 p.m., completed by LVN K, indicated new orders per NP L for CBC, BMP, TSH, Lipids, A1C (A1C test is a common blood test used to diagnose type 1 and type 2 diabetes), LFTs (Liver function tests are blood tests that can provide information about how the liver is working. They test the levels of a number of proteins and enzymes that are either produced by liver cells or released into the blood when liver cells are damaged.), UA, and chest x-ray. Record review of lab results dated [DATE] for CR#1 indicated the following: BUN (blood urea nitrogen) 64 high (reference range ,d+[DATE]) (high levels in blood sample usually mean kidneys aren't working normally . can be a sign of kidney disease or failure. Higher than normal BUN levels may also indicate dehydration, high-protein diet, medications, [CONDITION(S)] or other conditions.) The ADON documented on the lab results sheet NP L was notified on [DATE], no new orders, and push fluids. The lab results also indicated the following: Basic Metabolic Bun 64 High , reference range ,d+[DATE] Calcium 7.6 Low, reference range 8.,d+[DATE].2 Chloride 97 Low, reference range ,d+[DATE] Creatinine 4.70 High, reference range 0.,d+[DATE].20 Glucose 212 High , reference range ,d+[DATE] Potassium 4.1 , reference range 3.,d+[DATE].1 Sodium 133 Low, reference range ,d+[DATE] CO2 20 Low, reference range ,d+[DATE] Hepatic Panel [MEDICATION(S)] 3.0 Low, reference range 3.,d+[DATE].2 Alkaline Phosphatase 213 High , reference range ,d+[DATE] ALT 171 High, reference range ,d+[DATE] AST 113 High, reference range ,d+[DATE] Total Protein 6.1 Low, reference range 6.,d+[DATE].3 Hemoglobin A1C 6.70 High, reference range 4.,d+[DATE].20 Complete Blood Count WBC 14.9 High, reference range 4.,d+[DATE].2 RBC 3.14 Low, reference range 4.,d+[DATE].10 HGB 9.4 Low, reference range 14.,d+[DATE].1 HCT 28.8 Low, reference range 42.,d+[DATE].3 Absolute Neutrophils High, reference range ,d+[DATE] Absolute Eosinophils 0 Low, reference range ,d+[DATE] Lymphocytes % 6.2 Low, reference range 12.,d+[DATE].0 Urinalysis Clarity cloudy, reference range - clear Leukocytes Large, reference range - negative Protein >= 300, reference range - negative/trace Blood Large, reference range- negative During an interview on [DATE] at 5:00 p.m., NP L said she received a call from the facility regarding CR#1's lab results. She said she did not have the call in her call history. She said the ADON reported lab results indicated he was severely dehydrated and she gave verbal orders for IV fluids with follow-up labs for CBC and CMP after the bag was finished. She said it was her standard order for residents who were severely dehydrated. She said she never received a text or fax of the lab results as she usually did from the facility's nursing staff. During an interview on [DATE] at 5:33 p.m., the ADON said she circled the high lab values and reported the values to NP L. She said NP L gave verbal orders to push fluids by mouth and did not order IV fluids. She said it could have been a miscommunication. She said she did not text or fax the lab results to NP L or MD M. She said she could not recall why she did not text the results to NP L. She said CR#1 was able to drink and was encouraged to hydrate with ice and his cups were filled with water. She said CR#1 had his own personal cup that was kept filled with water and he received water with his meal trays. Record review of progress note dated [DATE] at 2:34 a.m., completed by LVN A , indicated CR#1 was lying in bed with eyes closed, rise and fall of chest noted, skin dry, intact, and warm to touch. RR 18, pulse 75, temperature 97.6, O2 98. Bed was in lowest position with fall mat next to bed, wheels locked and call light within reach. Record review of progress note dated [DATE] at 4:20 a.m., completed by LVN A, indicated LVN A was completing rounds at 3:50 a.m. and CR#1 was sitting on the side of the bed showing no signs of life, no pulse, and no O2 SATS or BP. There was no rigor mortis and his neck and abdomen were warm. LVN A immediately called for LVN D, pulled the crash cart and began CPR. Ambu bag (resuscitator mask) initiated with oxygen connected and compressions started until 911 EMS arrived and took over CPR. CR#1 was transferred to the hospital. NP B notified. Family member C notified. Record review of hospital records indicated CR#1 was transferred via EMS to the hospital on [DATE]. CR#1 was dead on arrival and he was pronounced deceased at 5:00 a.m. The admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . CR #1 was asystole on arrival and stayed asystole. Pupils were fixed and dilated. Partial rigor mortis at time of death. CR#1 was found non-responsive on the floor of his room. EMS arrived to the facility at 4:12 a.m. and facility staff was attempting CPR. EMS reported dried feces was stuck to his body and facility staff attempted to clean CR#1 during EMS performing CPR. During an interview on [DATE] at 12:55 p.m., MD M said he was not made aware of the condition of CR#1 and he should have been made aware. He said he was not made aware CR#1 was found unresponsive on [DATE]. He said if he was made aware of the lab results from [DATE] he (MD M) would have ordered in-patient IV fluids where he could see the resident daily. He said he would have talked to CR#1's family about a peg tube or hospice care. He said it would not make sense for NP L to order push fluids PO because CR#1 was severely dehydrated, had a [CONDITION(S)], and was probably septic. He said the dehydration cycle would have to be interrupted and when residents have dementia and were severely dehydrated they did not remember to drink. During an interview on [DATE] at 1:22 p.m., LVN K said normally when lab orders were received, a requisition was put off to the side for the night staff to complete. She said the lab requisitions were completed. She said for NP L, the lab results were faxed or texted. She said if it was critical, the lab would call. She said she never saw push fluids ordered for PO. She said she was not aware of the actual order for fluids for CR#1. During an interview on [DATE] at 1:46 p.m., the ADON said CR#1's lab results had no critical values. She said she called NP L and NP L ordered push fluids with no new orders. During an interview on [DATE] at 2:45 p.m., the DON said the ADON communicated CR#1's lab results to NP L over the phone and received push fluids by mouth as a new verbal order. She said CR#1's lab results were not uploaded to the e-chart or faxed to the physician before he was found unresponsive on [DATE]. She said the facility's Change in Communication policy dated ,d+[DATE] had been in effect since the company took over. She said the staff were taught from the policy and the expectation was the nursing staff would use the policy. The DON said the staff had access to all facility policies. Record review of the facility policy Change in Condition Communication dated ,d+[DATE] indicated physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patients/ residence condition, enter. Provide guidance for the notification of patients/ residents and their responsible party regarding changes in condition. F. Recent Labs, x-ray results . 2. Complete SBAR. 3. Notify the physician of the change of condition. (The physician notification grid may be used as a reference tool regarding acceptable notification timeframes.) The nurse will document all assessment and changes in the patient's/resident's condition in the medical record. Treat Required within 1 Hour Sodium (NA) Na > 150 or < 128; or any high or low NA with change in LOC or mental status . BUN, elevated >50% above usual in someone on diuretics or at high risk for dehydration or > 609 mg/dl . urinalysis-abnormal result on patient/resident with signs and symptoms possibly related or urinary tract infection or urosepsis (e.g. fever, burning sensation, pain, altered mental status) . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 4:50 p.m. The Corporate Nurse, Administrator and DON were notified and a plan of removal was requested. The Administrator was provided an Immediate Jeopardy template on [DATE] at 5:30 p.m. The following Plan of Removal was submitted and accepted on [DATE] at 12:53 p.m.: DON and Corporate Nurse reviewed Changes in conditions for physician notification, falls, abnormal labs and incident and accidents, medication errors, pressure ulcers, seizures, SOB, skin rash and abnormal Vitals to make sure they had physician notification and was done if needed on 9.7.22. Corporate Nurse and DON Re-educated facility nurses regarding physician notification and specifically regarding lab results on 9.7.22. Nurses will notify the physician via phone call of lab results and document in the electronic records. If no response, Nurse will notify Medical Director. If no answer Nurse will send patient to the hospital if it is a critical lab result. DON will incorporate this education as part of the onboarding education starting 9.8.22. Administrator will have a monitoring sheet to verify the education was done for new hires starting 9.8.22 Administrator will review at the morning meeting to verify that, if a patient change in condition requiring physician notification, The notification was done The physician orders a follow up if physician deemed it necessary The order was followed through Administrator was educated by Corporate Nurse on how to do this procedure on 9.8.22 POR Compliance date 9.8.22 On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of staff training dated [DATE] indicated all nursing staff were trained in person or by phone to notify the physician via phone call of lab results and document in the electronic records. If there was no response the nursing staff would notify the Medical Director. If there was no answer nursing staff would send the resident to the hospital if it was a critical lab result. Record review of new hire education indicated the DON incorporated physician notification and the facility policy as part of the onboarding education as of [DATE]. Record review of the facility's monitoring sheets indicated the Administrator would verify the education was done for new hires starting [DATE]. There were no new hires as of [DATE]. Record review of the monitoring sheets indicated the Administrator reviewed at the morning meetings on [DATE] and [DATE] to verify that a change in condition requiring physician notification was done, physician orders, a follow up if physician deemed it necessary and the order was followed through for 7 residents. Record review of staff in-service dated [DATE] indicated the Administrator was educated by Corporate Nurse on how to review a change of condition at morning meetings. During an interview on [DATE] at 4:15 p.m., the Administrator was able to verbalize the monitoring for change of condition procedures. She said the DON and the ADON were designees if she was not able to complete the monitoring during morning meetings. During an interview on [DATE] at 4:20 p.m. the DON and ADON was able to verbalize the monitoring for change of condition procedures. Record review of the facility's chart audit, dated [DATE], indicated the facility had completed 100% chart audit and notified the physicians of any changes or lab results as required. Interviews conducted on [DATE] from 10:00 a.m. through 4:30 p.m. with the DON, the ADON, 1 RN, and 6 LVNS, who worked all shifts, indicated they were trained to indicated they were able to correctly state the protocols for notification of the physician when there was a change of condition or a need to alter treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . An Immediate Jeopardy (IJ) situation was identified on [DATE] at 5:30 p.m. While the IJ was removed on [DATE] at 4:46 p.m., the facility remained out of compliance at a scope of isolated and actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and provide ongoing clinical assessment and identification of changes in condition for 1 of 8 residents (CR#1) reviewed for treatment and services. The facility failed to implement interventions and clarify a physician's order to ensure CR#1 received fluids after he had abnormal labs. CR#1 was found unresponsive on [DATE] and was pronounced deceased . The facility failed to immediately contact 911 for emergency services for CR#1. EMS was not contacted until approximately 12 minutes after CR#1 was found unresponsive on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 5:30 p.m. While the IJ was removed on [DATE] at 4:46 p.m., the facility remained out of compliance at a scope of isolated and actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving care as required and could result in death. Findings included: Record review of a face sheet dated [DATE] indicated CR#1 was a [AGE] year-old male resident admitted to the facility on [DATE]. CR#1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of physician order dated [DATE] indicated CR#1 was full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive. This process can include chest compressions, intubation, and defibrillation and is referred to as CPR). Record review of physician order summary dated [DATE] indicated there were no written orders for CR#1 regarding IV fluids or PO fluids. Record review of CR#1's MDS assessment dated [DATE] indicated CR#1 usually made self understood, usually understood others, had moderate impaired cognitive skills (made poor decisions; cues/supervision required), required extensive physical assist for ADLS, utilized a wheelchair for mobility, had an indwelling catheter, and was incontinent of bowel. Record review of a baseline care plan dated [DATE] indicated CR#1 was on antibiotic therapy. There was no comprehensive care plan for review as it was pending completion. Record review of CR#1's progress notes dated [DATE] at 12:15 a.m., completed by LVN J indicated CR#1's BP was ,d+[DATE], respiratory rate was 74 beats per minute, and O2 saturation was 100% on room air. LVN J notified NP L and received new orders to send to ER. LVN J called 911 at 12:35 a.m. The RP was called, there was no answer, and a message was left to call facility. At 12:50 a.m. EMS arrived and CR#1 was transported to the hospital at 12:55 a.m. Record review of progress note dated [DATE] at 1:48 a.m., completed by LVN J indicated the hospital reported CR#1 was alert, talking and discharged back to the facility on [DATE]. Record review of hospital records dated [DATE] indicated CR#1's BP was assessed numerous times and within normal limits. Record review of progress note completed on [DATE] 3:45 a.m., completed by LVN J indicated CR#1 returned to the facility with no new orders. Record review of progress note dated [DATE] at 1:25 p.m., completed by LVN K, indicated new orders per NP L for CBC, BMP, TSH, Lipids, A1C (A1C test is a common blood test used to diagnose type 1 and type 2 diabetes), LFTs (Liver function tests are blood tests that can provide information about how the liver is working. They test the levels of a number of proteins and enzymes that are either produced by liver cells or released into the blood when liver cells are damaged.), UA, and chest x-ray. Record review of lab results dated [DATE] for CR#1 indicated the following: BUN (blood urea nitrogen) 64 high (reference range ,d+[DATE]) (high levels in blood sample usually mean kidneys aren't working normally . can be a sign of kidney disease or failure. Higher than normal BUN levels may also indicate dehydration, high-protein diet, medications, [CONDITION(S)] or other conditions.) The ADON documented on the lab results sheet NP L was notified on [DATE], no new orders, and push fluids. The Urine Microscopic results indicated WBC -TNTC (In samples with very high bacterial concentrations, labs are often unable to get accurate counts and. report the results as too numerous to count) The [CONDITION(S)] panel indicated enterobacteria cloacae - high (can cause pneumonia, [CONDITION(S)], urinary tract and wound infections). During an interview on [DATE] at 5:00 p.m., NP L said she received a call from the facility regarding CR#1's lab results. She said she did not have the call in her call history. She said the ADON reported lab results indicated he was severely dehydrated and she gave verbal orders for IV fluids with follow-up labs for CBC and CMP after the bag was finished. She said it was her standard order for residents who were severely dehydrated. She said she never received a text or fax of the lab results as she usually did from the facility's nursing staff. During an interview on [DATE] at 5:33 p.m., the ADON said she circled the high lab values and reported the values to NP L. She said NP L gave verbal orders to push fluids by mouth and did not order IV fluids. She said it could have been a miscommunication. She said she did not text or fax the lab results to NP L or MD M. She said she could not recall she did not text the results to NP L. She said CR#1 was able to drink and was encouraged to hydrate with ice and his cups were filled with water. She said CR#1 had his own personal cup that was kept filled with water and he received water with his meal trays. During an interview on [DATE] at 12:55 p.m., MD M said he was not made aware of the condition of CR#1. He said if he was made aware of the lab results he would have ordered in-patient IV fluids where he could see the resident daily. He said it would not make sense for NP L to order push fluids PO because CR#1 was severely dehydrated. He said the dehydration cycle would have to be interrupted and when residents have dementia and were severely dehydrated they do not remember to drink. During an interview on [DATE] at 1:22 p.m., LVN K said normally when lab orders were received, a requisition was put off to the side for the night staff to complete. She said the lab requisitions were completed. She said for NP L, the lab results were faxed or texted. She said if it was critical, the lab would call. She said she never saw push fluids ordered for PO. She said she was not aware of the actual order for fluids for CR#1. During an interview on [DATE] at 1:46 p.m., the ADON said CR#1's lab results had no critical values. She said she called NP L and NP L ordered push fluids with no new orders. She said the aides would document in the e-chart what the residents received. She said push fluids meant ice in a cup and extra water. Record review of fluid intake sheets dated [DATE] at 9:59 p.m. and [DATE] at 9:59 p.m. indicated CR#1's fluid intake was 16. During an interview on [DATE] at 2:45 p.m., the DON said fluids were PRN and not documented accurately. She said CNA N meant to indicate 600 ml and not 16 ml. During an interview on [DATE] at 2:49 p.m., CNA N said she messed up and was supposed to document 600 cc for CR#1's fluid intake on [DATE]. She said she did not document CR#1's fluid intake. She said she made rounds every two hours and made sure his cup was filled up. She said he did not eat his supper and said he was tired and went to sleep. She notified the nurse CR#1 did not eat his supper. Record review of progress note dated [DATE] at 2:34 a.m., completed by LVN A , indicated CR#1 was lying in bed with eyes closed, rise and fall of chest noted, skin dry, intact, and warm to touch. RR 18, pulse 75, temperature 97.6, O2 98. Bed was in lowest position with fall mat next to bed, wheels locked and call light in reach. Record review of progress note dated [DATE] at 4:20 a.m., completed by LVN A, indicated LVN A was completing rounds at 3:50 a.m. and CR#1 was sitting on the side of the bed showing no signs of life, no pulse, and no O2 SATS or BP. There was no rigor mortis and his neck and abdomen were warm. LVN A immediately called for LVN D, pulled crash cart and began CPR. Ambu bag (resuscitator mask) initiated with oxygen connected and compressions started until 911 EMS arrived and took over CPR. CR#1 transferred to hospital. NP B notified. Family member C notified. Record review of EMS report dated [DATE] indicated the facility called 911 on [DATE] at 4:02 a.m. EMS was dispatched at 4:03 a.m. and arrived at the facility at 4:09 a.m. EMS took over CPR at 4:12 a.m. CR#1 was cold to touch and there was no rigor mortis (stiffening of the joints and muscles of a body a few hours after death) or dependent levity (reddish-blue discoloration of the skin resulting from the gravitational pooling of blood in the blood vessels evident in the lower lying parts of the body in the position of death) noted and left the facility at 4:49 a.m. There was dried feces noted on his left leg. CR#1 was lifeless and pulseless with asystole (the cessation of electrical and mechanical activity of the heart). He was intubated and transferred to hospital. Record review of hospital records indicated CR#1 was transferred via EMS to the hospital on [DATE]. CR#1 was dead on arrival and he was pronounced deceased at 5:00 a.m. The admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . CR #1 was asystole on arrival and stayed asystole. Pupils were fixed and dilated. Partial rigor mortis at time of death. CR#1 was found non-responsive on the floor of his room. EMS arrived at the facility at 4:12 a.m. and facility staff was attempting CPR. EMS reported dried feces was stuck to his body and facility staff attempted to clean CR#1 during EMS performing CPR. During an interview on [DATE] at 10:47 a.m., LVN D said LVN A came to the nurse station and said she found CR#1 on the floor and he was incontinent of bowel. She said LVN A asked for an aide to clean CR#1. She said she found an aide and then went to her medication cart. She said LVN A came back to the nurse station and said CR#1 had passed and was not breathing. She said she could not recall what the time was, but it was between 3:00 a.m. and 4:00 a.m. She said CR#1 was a full code and she grabbed the crash cart and went to his room. She said she checked to see if CR#1 had any signs of life, positioned CR#1 and compressions were started. She said 911 was yelled out. She said she could not recall who attached the AED. She said she did not know who called 911 or what time 911 was called. She said emergency protocols were to call 911 immediately when there are no signs of life. She said both she and LVN A did compressions until EMS arrived. She said she did not know how long compressions were performed. She said she could not recall if CR#1 had dried feces on him. She said the aides were not cleaning CR#1 of feces during CPR. During an interview on [DATE] at 9:33 a.m., LVN A said she usually made rounds every two hours. She said it was just before 4:00 a.m. when she was going to feed a resident across the hall from CR#1 and she saw CR#1 sitting on the floor next to his bed. She said his head was laying on the mattress of the bed. She said she checked for a pulse and there was no pulse. She said she called code blue and called for LVN D. She said LVN D grabbed the crash cart. She said CR#1 was a full code. She said she believed she put on the AED and LVN D put on the oxygen. She said she did not know who called 911. She said she and LVN D were calling code blue and 911. She said EMS arrived and took over CPR. She said she notified CR#1's son at approximately 4:50 a.m. She said she knew she saw CR#1 at 2:24 a.m., prior to the incident, because she was completing the Covid-19 assessments. She denied she found CR#1 on the floor incontinent of bowel. She said she did not ask for an aide to assist clean CR#1. During an interview on [DATE] at 2:00 p.m., Family Member C said he received a call from an unknown staff at 4:47 a.m. on [DATE]. He said the staff said she observed CR#1 asleep at 3:00 a.m. and a short time later he was slumped over and unresponsive. He said the EMS report said CR#1 went 22 minutes without EMS intervention and almost 15 minutes before they even called 911. He said the facility did not call 911 immediately. He said CR#1 was a full code. He said the hospital records indicated staff was trying to clean dried feces from CR#1 during CPR. During an interview on [DATE] at 11:50 a.m., the DON said nursing staff should do an assessment and if the resident is unresponsive initiate CPR, call code blue. She said calling code blue included getting the crash cart, notifying other nursing staff, yell out 911, and calling 911 if able. She said LVN A and LVN D were both performing CPR on CR#1. She said she knew they attached the AED because she had to replace the pads. She said CNA E and CNA F were providing care down the hall with the door closed and did not hear LVN D call code blue 911. She said CNA E and CNA F heard the nurse yell when they opened the door after completing care. She said she did know what time the staff called 911. During an interview on [DATE] at 11:50 a.m., the Administrator said she was the new administrator as of [DATE]. She said 911 should have been called immediately during an emergency. She said she was not aware of the incident on [DATE]. During an interview on [DATE] at 1:44 p.m., CNA E said she was providing care to another resident and CNA F came to assist. She said when CNA F opened the door she heard LVN D yell and told CNA F go and see what was going on. She said she completed the other resident's care and went to see what was going on and LVN D said call 911. She said LVN D was doing compression. She said LVN D said to tell 911 there was a resident that was unresponsive and then go and wait at the door to let EMS in the building. She said EMS arrived and she let them in the building and directed them to CR#1's room. She said she did not know what time it was when she called EMS and the call was not in her call log on her phone. She said 911 was supposed to be called immediately during an emergency. During an interview on [DATE] at 2:09 p.m., EMS G said CR#1 was laying on the floor and he was not breathing. He said there was feces all over from CR#1's belly button to his feet and it was dry. He said CR#1's eyes were fixed and dilated, he was very cold to touch, and he was naked. He said there was no rigor and that was the only reason they continued CPR. He said there was no pulse and CR#1 stayed asystole during transport to the hospital. He said staff attempted to clean the feces during CPR. He said CR#1 probably lost control of bowels when he became unresponsive but it was dry when EMS arrived. He said he could not recall the staff's name but a staff said she had spoken to CR#1 10 minutes earlier. CNA F was called on [DATE] and [DATE] and her voicemail was full. She was also sent text messages to call the surveyor on [DATE] and [DATE] and did not respond. CNA F's statement dated [DATE] indicated she was in the restroom and then went to help CNA E and heard a nurse say they had an emergency. She went in CR#1's room could see a nurse doing CPR and say to call 911 and CNA E called 911. During an interview on [DATE] at 12:45 p.m., CPR Instructor I said 911 should be called immediately when staff find someone unresponsive. He said staff should do an initial assessment and then call 911. He said one person should call 911 and the other person should continue CPR. Record review of LVN A and LVN D's personnel files indicated they had current CPR training and were trained on facility emergency procedures. Record review of the facility policy Change in Condition Communication dated ,d+[DATE] indicated physicians. And nursing staff to promote optimal patient/ resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patients/ residence condition, enter. Provide guidance for the notification of patients/ residents and their responsible party regarding changes in condition. F. Recent Labs, x-ray results . 2. Complete SBAR. 3. Notify the physician of the change of condition. (The physician notification grid may be used as a reference tool regarding acceptable notification timeframes.) The nurse will document all assessment and changes in the patient's/resident's condition in the medical record. Treat Required within 1 Hour Sodium (NA) Na > 150 or < 128; or any high or low NA with change in LOC or mental status . BUN, elevated >50% above usual in someone on diuretics or at high risk for dehydration or > 609 mg/dl . urinalysis-abnormal result on patient/resident with signs and symptoms possibly related or urinary tract infection or urosepsis (e.g. fever, burning sensation, pain, altered mental status) . Record review of the facility's Verbal Order policy dated 2001 (revised [DATE]) indicated shall only be given in emergency or when the Attending Physician is not available to the right or sign the order. will always be based on a verbal exchange with the prescribing practitioner or on an approved written protocols.5. The individual receiving the verbal order will: a. read the order back to the practitioner to ensure the information is clearly understood, incorrectly transcribed; to include medication/treatment dosage or quantity/measurement, how often and stop date if available. b. record the ordering practitioners last name and his or her credentials (MD, NP. PA, etc.); and c. record the date and time of the order. Record review of the facility's undated Emergency Nursing Procedures indicated . 4. Nursing interventions will be executed to prevent further deterioration and stabilize the resident's condition. 5. Call 911. Record review of facility's Cardiopulmonary Resuscitation Policy dated 2001 (revised ,d+[DATE]) indicated Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS) including defibrillation, for victims of [CONDITION(S)]. 6. If an individual (resident, visitor, staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: . b. There are obvious signs of irreversible death (e.g. rigor mortis). This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 4:50 p.m. The Corporate Nurse, Administrator and DON were notified and a plan of removal was requested. The Administrator was provided an Immediate Jeopardy template on [DATE] at 5:30 p.m. The following Plan of Removal was submitted and accepted on [DATE] at 12:53 p.m.: Corporate Nurse and DON Reviewed residents in the building for orders or recommendations to push fluids or encourage fluids to make sure they had a physician order and a set amount and how often to administer on 9.7.22, no patients had such recommendation / order. Nurses at the facility were re-educated that when a physician orders to push fluid to put an order in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . We are structuring the order from physician to push fluid as an order from md to nurse. That is why we made it that the nurse puts an order in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . So, we do not need the CNAs to participate in the intervention. DON will run POC report to verify that there is documentation charting regarding fluid intake. Corporate nurse and DON reviewed patients onsite and confirmed that no patient needed 911 services at the time on 9.7.22. Facility staff in nursing department as well as other departments were re-educated by Corporate Nurse, DON and/or Administrator regarding the importance of calling 911 immediately in case of emergency on 9.7.22. Employees not on site were re-educated over the phone and corporate nurse, DON, or administrator ensured comprehension by asking staff to repeat or paraphrase the education. DON will incorporate this education as part of the onboarding education starting 9.8.22 POR Compliance date 9.8.22 On [DATE], the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Record review of all 53 residents chart audit dated [DATE] indicated there were no residents in the facility with physician orders related to fluid intake. Record review of nursing staff in-serviced dated [DATE] indicated all nursing staff were trained in person or by phone to clarify all orders to push fluids, put all orders to push fluids on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review the facility audit form dated [DATE] of the new employee check off list indicated the facility had no new employees as of the investigation with required training related to adding push fluid orders to the MAR, the amount and the frequency. Interviews conducted on [DATE] from 10:00 a.m. through 4:30 p.m. with the DON, the ADON, 1 RN, and 6 LVNS who worked all shifts, indicated they were trained to put all orders to push fluids on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility 24-hour reports dated [DATE] and [DATE] indicated no residents required 911 services. Record review of facility staff in-service dated [DATE] indicated all staff except 1 were trained in person or verbally on the phone to call 911 immediately in an emergency. Record review of facility nursing staff in-service dated [DATE] indicated all nursing staff were trained on the facility CPR and emergency nursing procedures. Interviews conducted with the DON, the ADON, 1 RN, 6 LVNS, and 4 CNAs, who worked all shifts, indicated they were trained to call 911 immediately in the event of an emergency. The staff was able to verbalize training was received. The staff reported that training covered mock drills and in-services. Staff could locate the AED/crash carts, code blue statuses are called loudly, the person who found unresponsive resident delegated tasks, documentation includes exact time of discovering unresponsive patient, calling 911, notifying family and physician and exact times CPR began and EMS arrival. Staff reported during a code status and CPR no other tasks should be completed. Staff reported that CPR is initiated immediately, resident is never left alone, and 911 is contacted immediately. Staff reported that CPR is only done when there was no pulse. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 5:30 p.m. While the IJ was removed on [DATE] at 4:46 p.m., the facility remained out of compliance at a scope of isolated and actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 8 residents (Resident #1) reviewed for supervision. The facility was aware on 8/02/22 Resident #1 wanted to leave the facility. The facility did not adequately supervise Resident #1 who eloped on 08/04/22 and his whereabouts were not known until he was found 5 days later on 08/09/22 and required hospitalization due to altered mental status, acute [CONDITION(S)], acute [CONDITION(S)], toxic metabolic [CONDITION(S)], [CONDITION(S)], moderate protein malnutrition, and alcoholism. This failure could result in residents at risk of elopement, injuries, hospitalization , or death. An Immediate Jeopardy situation was identified on 08/19/22 at 3:25 p.m. The Immediate Jeopardy was removed on 08/20/22 at 1:32 p.m. The facility remained out of compliance at a scope of isolated and a severity of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Findings included: Record review of a face sheet dated 08/06/22 indicated Resident #1 was a [AGE] year-old male admitted from acute care hospital on 07/21/22. His diagnoses included lack of coordination, rhabdomyolysis (breakdown of damaged skeletal muscle), seizures (sudden, uncontrolled electrical disturbance in the brain), alcohol dependence, history of Covid-19 (infectious disease caused by the [CONDITION(S)]-CoV-2 virus), dysphagia (difficulty swallowing), generalized muscle weakness, bacteremia (the presence of viable bacteria in the circulating blood), unspecified altered mental status, unspecified abnormalities of gait and mobility, and other symbolic dysfunctions (organic-based language deficits). Record review of an admission MDS dated [DATE] indicated he expected to be discharged to the community. Resident #1 had a moderate cognitive impairment with a BIMS score of 12. He had no diagnosis of serious mental illness, intellectual disability, or related condition. He was admitted from an acute care hospital for rehabilitation. He was usually understood and was able to understand others. He wore glasses. He had disorganized thinking. Behaviors included physical behaviors directed at others, verbal behavioral symptoms directed at others, and behavioral symptoms not directed toward others, he rejected care, and did not exhibit wandering behaviors. He required limited assistance of 1 staff for bed mobility and transfers and eating. He required supervision (oversite, encouragement, cueing) for locomotion on unit. He required extensive assist for toilet use and personal hygiene. He utilized a wheelchair for mobility. He had falls with no injuries prior to admission. He coughed or choked during meals or when swallowing medications. His diet was mechanically altered. He had no skin conditions, ulcers or wounds. The baseline care plan dated 07/21/22 indicated Resident #1 would remain in the facility, discharge was not initiated, and he required one person physical assist for personal hygiene and mobility. He was alert and cognitively intact. He was always incontinent. Resident #1's comprehensive care plan was due on 08/04/22, the day he left AMA from the facility and was not completed or available for review. Review of a physician order summary dated 08/06/22 indicated Resident #1's medications included [MEDICATION(S)] ER for anxiety, [MEDICATION(S)] for anxiety, and [MEDICATION(S)] for seizures. Record review of elopement assessment completed 08/01/22 indicated Resident #1 was not a risk for elopement. Record review of progress note dated 08/01/22 and completed by LVN N indicated Resident #1 had an elopement score of 0.0. Record review of progress note dated 08/04/22 at 12:15 p.m., completed by LVN K indicated an aide assisted Resident #1 in his wheelchair to the dayroom to finish eating his lunch. Record review of progress note dated 08/04/22 at 4:12 p.m., completed by LVN M, indicated LVN M was sitting at the desk at 12:00 p.m. when the resident was rolling around, therapist had Resident #1's tray and took Resident #1 into the dayroom to assist the resident with feeding . Resident #1 insisted he needed to use the restroom and was assisted by an aide. Resident #1 returned to the dayroom to eat his lunch. At approximately 1:00 p.m. a MA was looking for the resident and LVN M went to assist to locate Resident #1. Record review of progress note dated 08/04/22 at 4:49 p.m., completed by the DON indicated Resident #1's friend was at the facility to visit the resident while Resident #1 was stating he wanted to leave and go to the store for a beer. During an interview on 08/18/22 at 3:42 p.m., the Administrator said Resident #1 was alert and oriented. He said he was admitted on [DATE] and left the facility AMA on 08/04/22. He said on the evening of 08/02/22, Resident #1 kept saying he wanted a beer and he wanted to go home. The administrator said he informed Resident #1 that he would get in touch with family member D. He said Resident #1's family member J had already called and reported the resident was going to try and leave. He said he talked to Resident #1 about AMA. He said Resident #1 refused to sign the AMA. He said Resident #1's family member D was not called when Resident #1 refused to sign the AMA. He said Resident #1 was rolling around the facility on 08/04/22. He said Resident #1 was not able to feed himself. The Administrator said he did not know if Resident #1 could care for himself. He said no interventions were put in place to prevent Resident #1 from leaving the facility because Resident #1 was his own RP and he had no diagnoses or orders to prevent him from leaving the facility. Record review of an AMA form dated 08/04/22 indicated Resident #1 refused to sign the form. The form was signed and dated 08/04/22 by the DON. The form indicated a vocal order was obtained from NP B on 08/04/22. During an interview on 08/11/22 at 1:25 p.m., COTA L said Resident #1 moved throughout the facility using his wheelchair and holding on the rails on the hallways. He said Resident #1 was assisted to eat his meal on 08/04/22. COTA L said he was not aware of Resident #1 exit seeking or attempting to leave the facility. During an interview on 08/06/22 at 5:00 p.m., ST H said she assisted Resident #1 with his lunch meal on 08/04/22. She said he could not feed himself. She said Resident #1 was assisted to the dayroom/TV room by staff. She said he was in a wheelchair and was able to move around the facility. During an interview on 08/11/22 at 1:45 p.m., CNA I said Resident #1 was assisted by ST H with his lunch meal. He said he brought Resident #1 to the dayroom/TV room and ST H assisted with his feeding. He said it was around 1:00 p.m. or 1:15 p.m. when he asked Resident #1 if he wanted to go to his room to rest, Resident #1 said No. He said it was around 1:30 p.m. when he went to take out the trash and another staff was not able to find Resident #1. He said Resident #1 had a visitor in a truck outside of the facility, but he did not see Resident #1 outside. He said Resident #1 was not exit seeking. He said he did not see Resident #1 leave the facility or attempt to leave the facility. He said he checked the unlocked janitor closet and other closets and rooms. He said he walked around the perimeter of the facility and did not see Resident #1. He said he walked around the block and behind the facility. He said Resident #1's visitor and Resident #1 were not in the parking lot. During an interview on 08/19/22 at 6:31 p.m., CNA E said Resident #1 was at the time clock area on 08/04/22 before the lunch meal and said he wanted to leave the facility. She said the resident did not understand where he was or why he was at the facility. She said she told him he lived at the facility, and he said okay. She said she told the nurses at the nurse station Resident #1 wanted to leave. CNA E could not recall who was at the nurse station or the names of the nurses. She said the resident was not able to have a conversation or walk. She said he needed assistance due to incontinence of bladder and bowel, to get dressed, and to eat. During an interview on 08/11/22 at 1:34 p.m., LVN M said she saw therapy assisting Resident #1 with his lunch on 08/04/22. She said she then saw Resident #1 at 12:15 p.m. in the TV room. She said she went to the dining room and then was called back to the nurses' station because a med-aide was not able to find him. She said all of the therapy rooms, resident rooms, other closets, and rooms were checked. She said no one could find him. She said he was not exit seeking. During an interview on 08/18/22 at 3:42 p.m., the DON said Resident #1 was not observed leaving the facility on 08/04/22. She said when residents are admitted they are made aware of the AMA policy. She said she had multiple conversations with Resident #1's family member D and family member J regarding their requests that the facility restrain Resident #1. She said the family wanted the resident restrained because they had previous incidents with him going on drinking binges. She said Resident #1 kept saying wanted to leave the facility. She said he had behaviors on some days where he would fight staff physically and verbally. She said Resident #1 was still going through detox. She said he would throw himself around on one day and a couple of days later he would be coherent. She said he was calm the day or so before he left the facility. She said she told him he could leave if it was done safely. She said on 08/04/22 Resident #1 said he wanted to leave. The DON said she did call the NP to report the Resident #1 wanted to leave the facility. She said she called Resident #1's family member D and the family member J indicated he, and family member O and a friend were coming to the facility for a meeting about the insurance. She said when Resident #1's family member D arrived at the facility on 08/04/22, he called the friend who said he waited in the parking lot under the tree and got tired of waiting and left. She said the family member D asked the friend if he saw Resident #1 and the friend hung up the phone. She said she did not report to the state because it was not considered an elopement or missing because he said he wanted to leave. She said the police were notified on 08/04/22 and were at the facility when family members D and O arrived. She said the police left because he did not have a diagnoses of mental impairment and was his own RP and left AMA. She said she did not call APS because Resident #1 was his own RP and was able to make his own decision to leave the facility. She said she thought about contacting APS, but he left AMA with a friend. She said she did not see when he left, how he left, or who he left with. She said she had no idea where he was going. The DON said the facility did not implement any interventions or increase supervision for Resident #1 when he said he wanted to leave, and he did not sign the AMA. She said she did not ask anyone to pick him up or try to get alternative placement. She said the physician did not okay for Resident #1 to leave the facility and that was the reason she had the AMA form completed. During an interview on 08/19/22 at 4:42 p.m., family member D said he had not received any calls from the facility that Resident #1 wanted to leave. He said the facility called and said Resident #1 was missing. He said he was called on 08/04/22 at 1:28 p.m. He said Resident #1 was not able to remember telephone numbers and could not call anyone to pick him up from the facility. He said family member O called his friend and the friend had not seen Resident #1. He said he did not believe Resident #1 left the facility. During an interview on 08/06/22 at 4:20 p.m., the Administrator and the DON said Resident #1 left the faciity on [DATE] AMA. The administrator said Resident #1 was his own RP. He said he had a BIMS of 12 and was cognizant. The administrator said he was alert and oriented. The DON said Resident #1 was not ambulatory but utilized a wheelchair. The DON said he ate lunch with assistance from ST H. The DON said he left with a friend. The Administrator said his family refused to take him back into their home. They said Resident #1 did not want to stay living at the facility. The Administrator said the family wanted the facility to keep him locked in the facility. The doctor was notified when he left. They did not call APS. They said he was not exit seeking. The Administrator said Resident #1 wanted to leave to get beer. The Administrator said we did not have any orders to keep him in the secure unit. They said they called the police, and the police were at the facility on 08/04/22 by 1:43 p.m. They said the police went to the friend's house and no one would answer the door or was in the house. During an interview on 08/11/22 at 1:22 p.m., PO P said he arrived at the facility on 08/04/22. He said Resident #1 had no diagnoses to prevent his leaving the facility. He said Resident #1 was not located in the facility or at the friend's house. He said a report was sent to two additional precincts and Resident #1 was not located. He said a report was not completed because Resident #1 was not considered a missing person and was able to leave the facility of his own choice. Record review of a progress note dated 08/05/22 at 10:35 a.m., completed by the DON, indicated the police department reviewed Resident #1's medical diagnoses and indicate there was no diagnoses to stop the resident from leaving the facility. The police would visit with the friend and update the facility. Record review of progress note dated 08/05/22 at 10:44 a.m., completed by the DON, indicated NP B was notified Resident #1 left the facility AMA. During an interview on 08/19/22 at 12:39 p.m., NP B said Resident #1 was cognizant and said he did not want to be in the facility. She said she saw him in the facility the morning of 08/04/22 and he was using his wheelchair to move around the facility. She said she made rounds at approximately 12:30 or so on Thursdays. She said the facility called her after Resident #1 left the facility AMA on Thursday 08/04/22. During an interview on 08/19/22 at 10:35 a.m., MD A said Resident #1 was cognizant and utilized a wheelchair to move around the facility. He said when he talked to Resident #1 prior to the resident leaving the facility, Resident #1 was alert and oriented but constantly wanted to drink beer. He said Resident #1 was able to make his needs known. He said he told Resident #1 he had the right to drink but not while he was under his (MD A's) care. He said Resident #1 never said he was going to leave the facility. Progress note dated 08/09/22 at 1:20 p.m., completed by LVN M, indicated late entry 10:55 a.m., indicated maintenance supervisor Q found Resident #1 in a housekeeping closet, naked, with his feet hanging out. He was alert and verbal. (11 was called. Resident #1 was transferred to a wheelchair. He indicated he did not want to be touched. EMS arrived and took over assessment. NP was notified. New orders for CBC, CMP, reactive protein, and a UA. At 11:45 a.m., EMS found Resident #1 was stable with vitals at 113/88,, O2 97%, on room air, and clear bowel sounds. Skin assessment indicated redness to top of ears, neck, upper chest, bilateral arms from middle of upper arms to hand. Resident #1 had swelling to bilateral feet and ankles with plus 2 [CONDITION(S)]. Resident #1 had an unstageable wound to the middle back on the spine 4 X .5 X 0, unstageable wound to coccyx 7 X 4.5, back of left leg 12 X1, , peri area was red and blanchable, back of right leg 15 X 2 , right arm has scattered bruising and scabs, left arm scattered scabs, right hip 3.4 x 2.5 red, blanchable area, right side of back 3 X 6 x ,9 DTI with a small red line that went from 1 side of the upper back to the other side crossing the scapula. No redness in groin or buttocks area. During an interview on 08/10/22 at 5:59 p.m., EMS R said the rescue squad reported Resident #1 was found in the locked closet in a bucket sitting in feces and urine. He said it did not look like Resident #1 was in the closet for four or 5 days. He said Resident #1's vital were stable and Resident #1 said he wanted to be left alone. He said he left Resident #1 at the facility but returned when MD A ordered Resident #1 transported to the hospital as the facility had discharged him on 08/04/22 when he left AMA. He said Resident #1 did not respond to questions when he was transported to the hospital. During an interview on 08/11/22 at 1:34 p.m. LVN M said maintenance supervisor Q and a house keeping staff came up to the nurse's station and said Resident #1 was in the closet. She said she went there and noticed he was sitting in a floor washing bucket. She said he was naked but pretty clean with the exception of his incontinence of bladder and bowel in the bucket. She said his clothes were clean and dry and set off to the side of the bucket. She said there was also a clean adult diaper next to the clean clothes. She said he was transferred to a wheelchair and taken to a room and laid on a bed. She said she left the room to get blood pressure cuff and EMS had arrived by the time she returned. She said he did not look like he had been in the closet for days. She said the closet was never locked because it was not used by housekeeping staff. She said he had no excoriation and the tops of his ears looked sunburned. She said his chest, lower arms had redness from the sun. She said his lips were not dry or cracked. She said he looked completely hydrated. During an interview on 08/11/22 at 1:45 p.m., CNA I said Resident #1 was found in a housekeeping/janitorial closet. He said he knew Resident #1 was not in there on the day he went missing on 08/04/22 because he checked the closet and it was not usually locked. He said Maintenance supervisor Q found Resident #1 in the closet after he unlocked the closet. He said he told LVN M and brought a wheelchair. He said he assisted Resident #1 to the wheelchair. He said he was clean except for the incontinence in the bucket. He said Resident #1 said he wanted to be left alone. During an interview on 08/11/22 at 2:17 p.m., maintenance supervisor Q said he was checking the breakers and there was a breaker box located in the housekeeping/janitor closet. He said the closet was not usually locked because it was no longer in use housekeeping staff. He said he unlocked the door and saw Resident #1 was sitting in the mop bucket. He said Resident #1 was naked. He said he called for CNA I and CNA I called for LVN M and brought a wheelchair. Record review of hospital records dated 08/09/22 indicated Resident #1 was admitted due to altered mental status, acute [CONDITION(S)] (a lower than normal potassium level in your bloodstream. Potassium helps carry electrical signals to cells in your body. It is critical to the proper functioning of nerve and muscles cells, particularly heart muscle cells.), acute [CONDITION(S)], toxic metabolic [CONDITION(S)] (results from an acute cerebral dysfunction due to different metabolic disturbances including medications or illicit-drugs), [CONDITION(S)], moderate protein malnutrition, and alcoholism. Record review of hospital records dated 08/09/22 indicated Resident #1 had multiple wounds noted to the following areas: behind right knew 0.5 X 0.5 cm. no drainage or odor noted, Behind left knee -0.25 x 1.0 cm. No drainage or odor noted, Middle back - 3 x 0.5 cm. No odor or drainage noted, Right back - 3 x 4 cm. No odor or drainage noted, Coccyx - 7 x 6 cm. No drainage noted, and BIL upper extremities-multiple scabs noted. No odor or drainage. Record review of hospital lab report dated 08/10/22 indicated Resident #1's urine drug screen was positive for [NAME] (Benzodiazepines (sometimes called benzos) work to calm or sedate a person). There was no urine drug screen for 08/09/22. Record review of hospital lab report dated 08/10/22 indicated Resident #1's blood alcohol level was <10 (one tenth of a percent of a person's blood volume is alcohol or that a person has 1 part alcohol per 1000 parts blood. At a blood [MEDICATION(S)] level of less than 50 mg/dL, or 0.05% concentration, an individual is not considered to be intoxicated. The possible critical value for blood [MEDICATION(S)] is >300 mg/dL). There was no blood alcohol level test for 08/09/22. During observation and interview on 08/11/22 at 8:30 a.m., Resident #1 was lying in a hospital bed. He was not able to answer any questions and did not respond to his name. He had numerous bruises and marks over his upper and lower extremities. The urine in his Foley bag was dark amber brown. He had a breakfast tray on the bedside table at the foot of his bed. During an interview on 08/11/22 at 8:45 a.m., RN C/ hospital nurse said Resident #1 was not able to walk or feed himself. She said he would occasionally respond to his name. She said there was no cause identified for his condition. She said he was tested for drugs on the day he was admitted to hospital on 08/09/22 and he tested positive for benzodiazepines (benzos) She said he did not receive benzos in the hospital. She said he was tested for alcohol a day after his admission to the hospital on 08/10/22 and it was <10. Record review of the facility's AMA policy dated 01/01/22 indicated Centers will honor requests for discharge against medical advice (AMA) by the patient or resident representative with legal authority to make decisions for the patient. AMA discharges will be processed in accordance with the patient's/resident representative's request to arrange discharge Appropriate discharge documentation will be completed as applicable. Referral to Adult Protective Services will be made when appropriate. PURPOSE To permit patients to exercise their rights under the law. PROCESS 1. In the event a patient who has medical decision-making capacity requests discharge AMA: 1.1 The nurse will: 1.1.1 Attempt to discern the reason for the patient wanting to leave and attempt to address any relevant issues. 1.1.2 Provide the patient an explanation of the benefits of remaining in the facility and the potential consequences, risks or complications of leaving the facility against the advice of the physician. 1.1.3 Immediately notify the Physician/Advance Practice Provider (APP) and the resident representative that the patient wishes to discharge himself/herself. 1.1.4 Immediately notify the Administrator, Director Of Nursing, and Director of Social Services of an AMA discharge request. 1.1.4.1 A determination of risk will be made by the physician/APP, Admin, DON, and/or Director of Social Services. For patients who are determined to be high risk, contact the Ombudsman, Adult Protective Services, law enforcement (when applicable) 2. The Administrator or designee will notify the Medical Director. 3. In the event a patient who has medical decision making capacity requests a discharge AMA but whose resident representative refuses, the patient's wishes are honored over the resident representative. 4. In the event the resident representative requests discharge AMA, the nurse will try to ascertain if it is the patient's wish to be discharged . 4.1 If a patient who has medical decision-making capacity does not wish to leave, the nurse will inform the resident representative and the patient's wishes will be honored. 4.1.1 If the resident representative is unwilling and insists on discharging the patient AMA, contact the Ombudsman, Adult Protective Services and law enforcement (when applicable), and Genesis Law Department. 5. If a patient lacks medical decision making capacity and insists on discharge AMA: 5.1 Notify the physician/APP, Administrator, Director Of Nursing, and/or Director of Social Services. 5.2 Attempt to discern the reason for the patient wanting to leave and attempt to address any relevant issues. Documenting the AMA: 6. The patient and/or resident representative will sign the Voluntary Discharge Against Medical Advice form and it will be placed in the clinical record. 6.1 If patient and/or resident representative refuses to sign, the nurse writes refused to sign on AMA form, signs the form and a second staff member signs as a witness and it will be placed in the clinical record. 7. Documentation will be made in the medical record with details of the discharge to include: 8.1 Persons and agencies notified; 8.2 Statement of reason for discharge (if known); 8.3 Explanation of benefits of remaining in the Facility; 8.4 Explanation of potential complications, risks, and consequences of leaving the Facility against the advice of the physician; 8.5 Date and time of discharge, mode of transportation, and by whom The Administrator and DON were notified on 08/19/22 at 3:25 p.m., that an IJ situation was identified due to the above failure and an IJ template was provided. The facility's Plan of Removal was accepted on 08/20/22 at 9:15 a.m., and included the following interventions: Patient is currently not onsite Administrator or Designee spoke with patients onsite to see if anyone needed facilitating a discharge on 8.19.22 no patients indicated they wanted to leave. Administrator was re-educated by CNO or designee on 8.19.22 regarding -Documenting if a patient says he wants to leave ama -Seeing if the patient would wait for the facility to facilitate a safe discharge and document it -If patient does not want to wait document it and see if facility can facilitate a as safe as possible ama discharge by asking about, Home health, DME, Medication, Physician in the community, Where the resident would go, Who would take the resident there, Notifying the family, Notifying the attending physician at the facility. Notifying the police upon discharge. -If a patient says he wants to go AMA to let the staff know to increase the level of supervision and document it Administrator or designee educated facility staff on 8.19.22 in person or by phone regarding Documenting if a patient says he wants to leave AMA to -Documenting if a patient says he wants to leave AMA -Seeing if the patient would wait for the facility to facilitate a safe discharge and document it On 08/20/22 the Surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Observation on 08/20/22 at 10:55 a.m. indicated there were no residents at the doors trying to leave the facility. During interviews on 08/20/22 from 10:50 a.m. to 1:30 p.m. with 5 residents (Resident #s 2, 5, 9, 10, and 11), indicated they did not want to leave the facility. Review of all 55-resident question/assessments indicated there were no residents who were leaving the facility. During interviews on 08/20/22 from 10:50 a.m. - 1:30 p.m. with 15 staff from all shifts (1 DON, 1 ADON, 1 RN, 4 LVNs, 1 MA, 3 CNAs, 1 BOM, 1 dietary manager, and 1 housekeeper) indicated they would report to the Administrator and DON of any resident that said they wanted to leave the facility. Nursing staff indicated they would document the information in the resident E-chart, document if the resident would wait for a safe discharge, if the resident would not wait for a safe discharge the facility would ask the resident about home health services, medical equipment, the name of their physician, where they planned to go, and who would take the resident. The nursing staff indicated they would notify the family and physician and would call the police. The nursing staff indicated they would increase supervision of the resident and document in the E-chart. The DON indicated the facility would notify the police and APS of all residents who left the facility with unsafe AMA. Record review of in-services dated 08/19/22 and 08/20/22 indicated all staff were in-serviced in person or by phone with the exception of one staff without a phone. During an interview with the DON on 08/20/22 at 1:30 p.m., she said the staff would be inserviced prior to their next scheduled shift. She all staff were sent the in-services via email or text and would sign the paper documents prior to their next scheduled shift. On 08/20/22 at 1:32 p.m. the DON was informed the IJ was removed; however, the facility remained out of compliance at a scope of isolated and a severity of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, which included [CONDITION(S)] care and tracheal suctioning, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 13 residents (CR #106) reviewed for respiratory and [CONDITION(S)] care. The facility failed to ensure CR #106's ventilator alarm was set appropriately according to the ventilator manufacture manual and/or ventilator company guidelines. CR #106 ventilator was not alarming when she was found lifeless with no pulse, she was transferred to the hospital and expired the following day. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents who are dependent on ventilators at risk of hypoxemia, hospitalization , and death. Findings include: Record review of CR #106's undated face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged to the hospital on [DATE]. She had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #106's Admit/Readmit screener dated [DATE] revealed she was alert and oriented to person, place, time, and situation. She had equipment upon admission which included [CONDITION(S)] and ventilator. Additional information for ventilator noted, AVAP - R - 16 IPAP 10 EPAP 7 tv 350. Further review of equipment revealed she had Respiratory treatment and [CONDITION(S)] (continuous positive airway pressure [[CONDITION(S)]] therapy -a common treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The comments for the [CONDITION(S)] noted, patient has a [CONDITION(S)] left at hospital [CONDITION(S)] used at night. Record review of CR #106's baseline care plan dated [DATE] revealed she had special treatments of oxygen therapy, suctioning, [CONDITION(S)] care and ventilator or respirator. Record review of CR #106's hospital discharge records dated [DATE] revealed she was admitted on [DATE] and her reason for visit was Acute Respiratory Failure with [CONDITION(S)]/Hypercapnia (represents a specific condition wherein competing mechanisms are simultaneously acting to increase [[CONDITION(S)]] and decrease [hypocapnia] brain blood flow, resulting in an adjustment that is ideal for neither the regulation of oxygen delivery nor tissue pH). Further review of the discharge record did not indicate ventilator settings or the residents' condition. Record review of CR #106's progress notes dated [DATE] at 8:38 PM by RT A revealed, Patient transported via EMS via stretcher from hospital at approximately 7:55 PM. Patient hooked up to vent, which settings are AVAPS VT 350 Rate 16 IPAP 10 EPAP 7 3L Bleed-in Oxygen. Patient has intact and clean #4 [CONDITION(S)]. HR 103 O2SAT 99%. Patient able to communicate. Patient tolerating well. No distress noted. Call light string and remote at patient bedside. Patient asked for water to drink and check on fans she had in room at hospital. Further review of the progress note revealed no mention of ventilator alarm settings. Record review of CR #106's progress notes dated [DATE] at 9:23PM revealed, Patient arrived via EMS in a stretcher around 8 p.m. Patient was placed in bed with the wheels lock, call light in reach. Respiratory came setup patient machine and oxygen. On call Doctor was notified about patient arrival waiting on medication reconciliation. Patient was given a sandwich and some water patient appears to not be in any pain she is laying comfortable in the bed resting with her eyes close. Record review of CR #106's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The average volume of as entering or leaving the lungs per minute). Further review of the order did not reveal information regarding ventilator alarm settings. Record review of CR #106's Detailed Written Order for Home Invasive Mechanical Ventilator from the Ventilator company dated [DATE] revealed her Trilogy Home Invasive Mechanical Ventilator was ordered to be set to: Mode - S/T (The S/T or Spontaneous/Timed mode offers a combination of machine delivered breaths [set respiratory rate] and spontaneous [patient triggered] assisted breaths), AVAPS on, VT target 350, Rate 16, EPAP 7, IPAP 10, IPAP max 25, O2 LPM (bleed-in) 3. Further review of order did not reveal information regarding ventilator alarm settings. Record review of CR #106's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #4 cuffed (A cuffed [CONDITION(S)] tube has a balloon cuff around the lower end of the [CONDITION(S)] tube. It is often used for people who need to use a ventilator or [CONDITION(S)] machine. When the balloon is filled, air will not leak around the [CONDITION(S)] tube). Record review of CR #106's progress notes dated [DATE] at 9:02 AM by RT A, revealed, Was informed patient had been pulling vent circuit off. HR 154 O2SAT 96%. Patient laying there with eyes close. On AVAPs rate ,d+[DATE], VT 274, Fio2 30% (Percentage of oxygen in the air mixture that is delivered to the patient), IPAP 10, EPAP 7, PIP 24.0 (the peak inspiratory pressure [PIP ] is the highest pressure measured during the respiratory cycle and is a function of both the resistance of the airways and the compliance of the respiratory system). Slight wheeze scattered. Suctioned small white thick secretions. Patient tolerated well. Record review of CR #106's progress notes dated [DATE] at 11:55AM by RT A revealed Heard vent going off. Entered room, found patient had pulled [CONDITION(S)] completely out. Patient was turning a grey/blue color. Re-inserted the [CONDITION(S)], placed back on vent. Patients HR 97 with O2SAT 94%. Patient is reaching to pull off again, nurse aide, came in to sit with patient while Nurse was going get [MEDICATION(S)]. Record review of CR #106's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #106's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #106's late entry progress note entered on [DATE] by the DON, dated to reflect [DATE] at 12:33 PM revealed Physician in to visit - he was made aware that resident had an elevated heart rate - respiration. Is currently on [MEDICATION(S)] - verbal order given to give one time dose of [MEDICATION(S)] 12.5 mg now and obtain labs in AM- CBC, CMP, lipid. Medication given per MD verbal order. Record review of CR #106's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #106's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #106's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #106's physician note dated [DATE] at 2:30 PM revealed in part, . patient currently on the vent on SIMV (Synchronized intermittent mandatory ventilation [SIMV] is a type of volume control mode of ventilation. With this mode, the ventilator will deliver a mandatory [set] number of breaths with a set volume while at the same time allowing spontaneous breaths). Tolerating well and has been put on [CONDITION(S)] (continuous positive airway pressure is a machine that uses mild air pressure to keep breathing airways open while you sleep) from time to time. Patient self is alert and showing that she wants to get off the ventilator . Respiratory therapist claimed no evidence of any fever or chills or any other complications. Patient has a [CONDITION(S)] with no complications at this point . Assessment/Plan 1. Dependence on respirator - discussed with respiratory therapist. Will put the patient on [CONDITION(S)] collar 5 minutes at a time and slowly build up her respiratory reserve and then will start weaning her off the ventilator. Breathing treatments every 6 hours Further review of the physicians note revealed no information regarding alarm ventilator settings. Record review of CR #106's progress notes dated [DATE] at 4:12 PM by RT A revealed Patient resting well, tolerating vent settings. No vent changes. HR 136 O2SAT 99%. Fine rales scattered. RR ,d+[DATE], VT 341, FIO2 35%, IPAP 10, EPAP 7, PIP 24.9. Suctioned small white thin secretions. Record review of CR #106's progress notes dated [DATE] at 6:57 PM by LVN B revealed, Resident very agitated and pulling at trachea and disconnecting tubing. Resident encouraged not to pull at tubing unsuccessful as resident is confused. Will continue to monitor. Record review of CR #106's ventilator tracking sheet dated [DATE] - [DATE], revealed CR #106's vent settings were checked approximately every 2 hours. Further review of the vent tracking sheet revealed no area regarding ventilator alarm settings. The ventilator tracking sheet showed starting on [DATE] at 9:02 AM CR #106 had an elevated heart rate of 154, the on [DATE] at 12:00 PM the heart rate was 94, on [DATE] at 2:00 PM the heart rate was 144, on [DATE] at 4:12 PM the heart rate was 136, and starting on [DATE] at 6:12 PM the heart rate went down to 88 and remained in the 80's through the last documented ventilator check on [DATE] at 4:00 AM . Record review of CR #106's progress notes, dated [DATE] at 5:18AM, by LVN C revealed, This nurse entered patient room at 5:00 AM due to patient's ventilator alarm machine sounding. 5:10 AM other nurse on shift notified me that resident was not showing any signs of life. CPR started until 911 EMS arrived and took over. Patient being transferred to hospital. Nurse Practitioner was notified of resident not showing any signs of life and transferred to hospital. RP notified at 5:18 AM. Record review of CR #106's hospital discharge summary from admitted d [DATE] revealed reason for hospitalization was PEA arrest (Pulseless electrical activity [PEA] refers to cardiac arrest in which the electrocardiogram shows a heart rhythm that should produce a pulse but does not). Further review of the discharge summary revealed in part, .presents for cardiac arrest. The patient was discharged about 2 days ago to a nursing home after being admitted for respiratory failure. The patient was seen apparently 5 - 10 minutes prior to 911 being called by EMS. EMS reported they arrived, and the patient was asystole (Asystole is a type of cardiac arrest, which is when your heart stops beating entirely. This usually makes you pass out. It's also likely that you'll stop breathing or that you'll only have gasping breaths. Without immediate CPR or medical care, this condition is deadly within minutes). The gave the patient epi ([MEDICATION(S)]) x 3 as well as epi drip. They report asystole was on the monitor the entire time. When the patient arrived in the emergency department there was no pulses felt however there was PEA on the monitor. We continued ACLS (advanced cardiovascular life support) protocols and continued CPR ROSC (Return of spontaneous circulation is the resumption of a sustained heart rhythm that perfuses the body after cardiac arrest) was achieved at 5:41 AM . So far, no evidence of brain activity . she appears terminal at this point . [DATE] family came and signed the TNDA (Texas Natural Death Act) consent. Patient died several hours later . suspect severe respiratory acidosis (Respiratory acidosis is a state in which there is usually a failure of ventilation and an accumulation of carbon [MEDICATION(S)]. This causes body fluids, especially the blood, to become too acidic) to blame for PEA Interview on [DATE] at 4:45 PM, LVN C said she worked the 10PM -6AM shift and she recalled CR #106 repeatedly trying to get out of the bed which caused her ventilator alarm to go off because her [CONDITION(S)] would disconnect. LVN C said the last time she heard CR #106's ventilator alarm go off was around 5:00 AM on [DATE]. LVN C said she went into the room to check on CR #106 when the alarm went off and the resident was fine. LVN C said the ventilator alarm cut off on its own and said whatever the issue was had resolved itself. LVN C said she left out of CR #106 room and continued with her rounds. LVN C said about 10 minutes later she heard LVN D yell out for her to come because there was a situation in CR #106 room. LVN C said she went into CR #106's room and she was lifeless with no pulse so they started CPR and had the CNA's call 911. LVN C said she did not hear CR #106's ventilator alarm going off before LVN D called her to the room. LVN C said LVN D reported she (LVN D) happened to be walking by CR #106 room and noticed from the hallway CR #106 color looked off. LVN C said LVN D reported CR #106 color being off was the cause of her to going into the room to check on CR #106 and discovered CR #106 with no pulse. LVN C said CR #106 ventilator alarm was not going off when LVN D went into CR #106 room and found her with no pulse. Interview on [DATE] at 5:30 PM, the DON said on [DATE] the nursing staff noticed CR #106 heart rate was high and she had some agitation because she kept pulling her [CONDITION(S)] out. The DON said the physician was notified of the heart rate and behavior and he came to the facility to assess CR #106. The DON said the physician's NP gave a verbal order to administer a one-time dose of [MEDICATION(S)] 12.5 mg to help with the elevated heart rate. The DON said the medication was given by the ,d+[DATE] PM shift nurse (LVN B) and said the order was not put into CR #106 electronic orders, but she (the DON) did chart in her note (the DON's late entry note) the medication was given. The DON said her note was a late entry because she did a look back of CR #106 chart and what had transpired and completed some of the charting late. The DON said in her look back of CR #106's discharge she learned LVN D was doing rounds when she found CR #106 unresponsive and initiated CPR. The DON said they called 911 and CR #106 was taken to the hospital. The DON said the staff monitored CR #106 every 2 hours on her ventilator sheet which showed her medications had worked and her heart rate stabilized. The DON said she did not know of any other changes or issues CR #106 had before she was found unresponsive. Interview on [DATE] at 5:45 PM, CNA E said she worked 2PM - 10PM on [DATE] and described CR #106 as being nervous and shaking a lot. CNA E said CR #106 kept grabbing at her [CONDITION(S)] and the staff would have to stop her and redirect her to leave it alone. CNA E said either herself, RT A, and LVN B were always in the room with CR #106 to keep her from pulling out her [CONDITION(S)]. CNA E said she did not know why CR #106 was grabbing at her [CONDITION(S)] and acted the way she did but said the nurse gave CR #106 some medication and she calmed down and went to sleep around 8:30 PM. CNA E did not know what medications CR #106 was given. Interview on [DATE] at 9:20 AM, CNA F said she worked the night shift with CR #106 on [DATE]. CNA F said she recalled CR #106 was irritated throughout the night and the nurse (LVN C) had to sit in the room with CR #106. CNA F said she could tell CR #106 was irritated because she would move around a lot because she did not want the [CONDITION(S)]. CNA F said she recalled CR #106's alarm going off a couple of times during her shift and she would see LVN C go into the room to check on CR #106. CNA F said she was doing her final rounds around 5 AM when she last heard CR #106 alarm go off and saw LVN C go into CR #106 room. CNA F said LVN C came out of CR #106 shortly after she went in and did not hear the ventilator alarm sounding anymore. CNA F said she did not hear CR #106 alarm go off again but a few minutes later she heard LVN D yelling out for them to come to CR #106 room. CNA F said CR #106 was unresponsive and the nurse's started CPR while she called 911. CNA F said, CR #106 coding seemed to come out of nowhere. Interview on [DATE] at 9:43 AM, LVN B said she worked 2PM-10PM on [DATE] and said she recalled CR #106 was very agitated throughout the shift. LVN B said CR #106 had a lot of anxiety and pulled at her [CONDITION(S)] which caused her ventilator alarm to go off repeatedly. LVN B said either her or RT A was constantly running to CR #106's room because the alarm was going off and they found her with her [CONDITION(S)] pulled out holding it in her hand. LVN B said they would reinsert the cannula and redirect her not to pull it out. LVN B said she recalled the DON told her about CR #106 new order for [MEDICATION(S)] 12.5 mg one time dose and said she did administer CR #106 the medication. LVN B said she also recalled administering some anxiety medication to CR #106 but could not recall what the medication was. LVN B said they had an aide (CNA G) come sit one on one with CR #106 until she finally calmed down. LVN B said CR #106 had calmed down enough to fall asleep but when she woke up, she would still be agitated and pulled at her [CONDITION(S)]. LVN B said she could not recall if she entered the [MEDICATION(S)] 12.5 mg order in the electronic record but said it was a busy shift and patient care came first so she may have forgot to go back and document the order and administration of the medication. Interview on [DATE] at 1:00 PM, CNA G said she worked on [DATE] from 11:30 AM - 7:30 PM and she recalled CR #106 panicking and trying to pull out her [CONDITION(S)]. CNA G said she was assigned to sit with CR #106 to make sure she would not pull out her [CONDITION(S)]. CNA G said she had to constantly redirect her and ask her to calm down and not pull at her [CONDITION(S)]. CNA G said she recalled LVN B came in and gave CR #106 some medication and she calmed down enough to fall asleep shortly after. CNA G said she had to go give showers, so LVN B came in to sit with CR #106 when she left. CNA G said CR #106 could communicate on paper and she wrote to her she did not like the [CONDITION(S)] and did not want it. CNA G said the nursing staff was aware CR #106 did not want the [CONDITION(S)]. Interview and observation on [DATE] at 2:30 PM, RT A presented CR #106 ventilator she used in the facility which was a Trilogy Vent 100. RT A was able to present the last few alarms alerted on CR #106's ventilator alarm log which showed the circuit disconnect alarm went off on [DATE] at 8:20 PM, 8:26 PM, 8:30 PM and 11:44 PM, then on [DATE] at 12:17 AM, 12:49 AM, 4:27 AM, 4:27 AM, 4:28 AM, 4:29 AM, and 4:44 AM. The last alarm noted in the log was on [DATE] at 9:50 AM which was AC Power Disconnect. RT A said if a resident was on a vent, and they died /had no pulse it would alarm apnea. RT A said circuit disconnect meant there was a disconnect in the circuit which could mean something was unplugged or disconnected. RT A said when the circuit disconnect alarm went off the staff should check the patient and assess why it was going off by checking all the lines and attachments to make sure they were connected. Observation and interview on [DATE] at 5:12 PM, CR #106's alarm settings were reviewed in her ventilator by RT A and state surveyors which showed the circuit disconnect alarm was set for 5 seconds. The alarm settings showed all other alarms were set to off which included: apnea alarm, low Vte alarm, high Vte alarm, Low minute ventilation alarm, High minute ventilation alarm, low respiratory rate alarm, and high respiratory rate alarm. RT A reiterated the apnea alarm would be the alarm to go off if she had no pulse and if just the circuit disconnect alarm was set the alarm would not go off for no pulse or respiratory distress. RT A said staff would have had to physically observe CR #106 during their checks to know she went into cardiac arrest (Cardiac arrest occurs when the heart suddenly and unexpectedly stops pumping) because the alarm would not have gone off in that situation. Interview on [DATE] at 5:15 PM, an EMS representative said the EMS records showed the facility called 911 on [DATE] at 4:51 AM for CR #106 cardiac arrest and the ambulance arrived at the facility on [DATE] at 4:58 AM. Interview on [DATE] at 5:33 PM, RT A said before residents with ventilators were admitted they coordinated with the ventilator company to deliver the ventilator before the resident admitted to the facility. RT A said the ventilator company got the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RT A said when the ventilator company RT delivered CR #106 vent to the facility, her and the vent company RT reviewed the settings together to ensure they were correct before she accepted the vent. RT A said they did look at the alarm settings and said if she noticed the alarms were off, she should have asked the vent company RT to set the apnea alarm. RT A said alarm settings were typically not specified in the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RT A said she had not noticed the alarms were not set for CR #106. RT A said there was a manual for the ventilator for the to refer to. Interview on [DATE] at 5:54 PM, LVN D said she worked the night of [DATE] but she was not CR #106 assigned nurse. LVN D said she recalled CR #106 ventilator alarm going off a few times over night and she saw LVN C went into the room to check the resident. LVN D said it was close to 5:00 AM on [DATE] when she happened to be walking down the hall and glanced into CR #106 room and noticed she looked pale. LVN D said she went into the room and checked for a pulse and CR #106 did not have a pulse, she called out for help and the CNA's and LVN C ran to the room and assisted with running a code blue (a code to rush to the specific location and begin immediate resuscitative efforts). LVN D said there was no ventilator alarm going off when she found CR #106, and her [CONDITION(S)] was still attached. LVN D said she could not recall if the alarm went off when she disconnected her from ventilator to perform CPR because she was focused on the patient. According to record review Resident #106's ventilator alarm log the last time CR #106 was disconnected was on [DATE] at 4:44 AM and prior to that, the alarm last went off at 4:29 AM which indicated a 15-minute window from the time she was potentially last checked by LVN C and when she was found lifeless and disconnected to perform CPR by LVN D. Interview on [DATE] at 12:15 PM, the Corporate Nurse provided the AARC Clinical Practice Guideline for Long-term Invasive Mechanical Ventilation in the Home - 2007 Revision and Updated and said the ventilator company reported using those guidelines. Record review of AARC (American Association for Respiratory Care) Clinical Practice Guideline for Long-term Invasive Mechanical Ventilation in the Home - 2007 Revision and Updated provided by the Corporate Nurse on [DATE] at 12:15PM revealed in part, .The patient eligible for invasive long - term mechanical ventilation in the home (HIMV) requires a tracheotomy tube for ventilatory support, but no longer requires intensive medical and monitoring services. This guideline refers to patient ventilated by positive pressure via a [CONDITION(S)] tube in the home . The setting is the home, which for the purposes of this guideline may be the patient's home, a foster home, or a group living environment . Contraindications to HIMV include: 5.1 The presence of a physiologically unstable medical condition requiring higher level of care or resources than available in the home. Examples of indicators of a medical condition too unstable for the home and long-term care settings are . 5.1.3 Need for continuous invasive monitoring in adult patients . 10.1.6 Alarms 10.1.6.1 A patient disconnect (eg, low-pressure or low-exhaled-volume) and a high-pressure alarm are essential. 10.1.6.2 If patient disconnection is likely to produce a serious adverse effect, a remote alarm and secondary alarm may be indicated. A secondary alarm may be used on chest-wall impedance and cardiac activity, exhaled volume, end-tidal CO2, or pulse oximetry with alarm capabilities Interview on [DATE] at 4:10 PM, the facility Pulmonologist said he was not familiar with CR #106 and said she discharged before he was able to meet/assess her. The Pulmonologist said in his experience with residents on ventilators in long term care, the apnea alarm was the most important alarm to be on. The Pulmonologist said for his patients he expected the apnea alarm to be on but said ventilator manufacturer should be the ones to set the alarms and the facility staff should not deactivate any alarms. The Pulmonologist said it was unfortunate CR #106's apnea alarm and other alarms were not turned on. Interview on [DATE] at 4:31 PM, the Vice President (VP) of the ventilator company said the high volume and circuit disconnect are the two alarms they set on the ventilators per the AARC Clinical Guidelines. The VP said the apnea alarm was [NAME] point (A debatable question, an issue open to argument; also, an irrelevant question, a matter of no importance) and they typically did not use it because it could cause alarm fatigue (occurs when clinicians experience high exposure to medical device alarms, causing alarm desensitization and leading to missed alarms or delayed response). CR #106 alarm settings were reviewed with the VP which revealed only the circuit disconnect alarm was on. The VP said he did not know why the high volume alarm would not be set but said it was usually their standard to set both alarms (circuit disconnect and high volume). The VP said they were required to service the machines the facility rents from them, not the patient, and said the facility should coordinate with them if they or physician want settings changed according to the patient's needs. The VP forwarded a copy of the contract between the ventilator company and the nursing facility that lists facility and ventilator company obligations. Record review of the Rental Contract for Medical Equipment between the ventilator company and nursing facility, provided on [DATE] at 5:12 PM by the ventilator company VP, dated [DATE], revealed in part, . C. Company is engaged in the business of renting and selling durable medical equipment . Lessee will lease from company and company will provide at the request of Lessee, items of durable medical equipment for Lessee's patients on an as-needed basis, as requested by Lessee, and strictly in accordance with any and all care plans approved by the patient's physician and Lessee . Lessee will initiate the equipment rental by furnishing to [NAME] a list of the equipment required for each patient. This list will be furnished by Lessee on a case-by-case basis and will be delivered to [NAME] pursuant to the notice requirements . Lessee is entitled during the period of use of any item of equipment to control, operate, and possess the equipment being lease, subject to the direction and supervision of approved personnel of Lessee Further review of the contract revealed an area circled by the VP titled Miscellaneous Services which revealed in part, .Other than the delivery, retrieval and repair and maintenance obligation, as set forth above, company shall have no service obligations whatsoever to the Lessee, other than as expressly agreed in writing between parties at mutually-agreeable rates. Any Respiratory Therapist services (area was underlined by VP), including without limitation, equipment set-up and routine maintenance, mask fitting, patient education, staff in-servicing, ,d+[DATE] on-call service for equipment malfunction or discomfort causing service interruption, 24 hour follow-p calls after set-up, 72 hour 3rd party quality control call, weekly compliance follow-up calls for first month, 31 - day and quarterly visits with compliance downloads and education, 7 day compliance program for patients having difficulty, oral and/or tracheal suction and care, clinical assessment, nebulizer treatments, MDI or inhaler treatment, pulse oximetry checks, arterial blood gas draws, and emergency response assistance, and any and all other miscellaneous services will be the sole responsibility of the Lessee, unless expressly agreed otherwise in writing . All services covered by this agreement must be ordered, evaluated, and supervised by Lessee. A registered Respiratory Therapist employed by Lessee will coordinate the services between Lessee and [NAME]. Lessee will retain professional management of the patient for the purposes of managing the patient's illness and treatment Interview on [DATE] at 9:40 AM, the ventilator company RT said she coordinated with RT A when she brought new ventilators to the facility. The ventilator company RT said she delivered the ventilator with the settings already set according to the physician orders. The vent company RT said upon delivery she did go over the settings with RT A to ensure they were correct. The vent company RT said the facility had access to the machines to make changes and said they were given instruction on how to unlock the screen to change the settings if needed. The vent company RT said she ensured RT A knew how to unlock the settings in the event there was an emergency and settings needed to be changed. The vent company RT said the vent company would not leave ventilator machines in facilities without them knowing how to get into the machine. Interview on [DATE] at 2:51 PM, CR #106 physician said CR #106 was not doing well at all and he knew CR #106 from her previous facility. The physician said he did not see CR#106 getting any better, he said she was aspirating constantly, she had dementia, and her brain was not functioning properly to protect her airway. The physician said before CR #106 came to the facility he had consulted with a case manager about hospice for CR #106 because he did not see her getting better. The physician said the family must have decided against hospice in the hospital because she came to the facility on a ventilator. The physician said he was going to speak with the family again regarding hospice and if they decided to still proceed with her receiving treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician said CR #106 coded before the conversations

Based on interview, and record review the facility failed to consult with the physician for 1 of 4 residents reviewed for admission and change of condition. (Resident #1) The facility failed to immediately consult with Resident #1's physician to notify him of Resident #1's admission and obtain orders to treat. Resident #1's hospital discharge records indicated the resident was a diabetic and required sliding scale insulin. The facility failed to notify the physician when Resident #1's blood sugars were above 246 mg/dl on four occasions. Resident #1's blood sugar on 1/16/22 was 597 mg/dl. He was discharged to the hospital on 1/16/22 unresponsive. Resident #1 required intubation (tube placed into the trachea to maintain an open airway) in the ambulance on the way to the emergency room . An Immediate Jeopardy (IJ) was identified at 2:00 p.m. on 01/26/22. While the IJ was removed on 01/27/22, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving appropriate treatment, deterioration of their physical condition, decreased quality of life and hospitalization . Findings included: Record review of Resident #1's face sheet indicated he was [AGE] years old and was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was discharged to the hospital on 1/16/22. Record review of the medical record indicated there was no available MDS for review due to Resident #1's admission status. Record review of Resident #1's baseline care plan dated 1/14/22 indicated Resident #1 was a diabetic and his medications included insulin. Review of Resident #1's discharge packet from the hospital faxed to the facility on [DATE] indicated there was no insulin or other diabetes medications included with the active medication list. Record review of Resident #1's cumulative physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The following medications were added in the electronic health record on 1/15/22 and 1/16/22: *1/15/22 [MEDICATION(S)] 5 mg tablet 1 tab PO QHS (a sedative) *1/15/22 [MEDICATION(S)] 50 mg 1 tab PO daily (antipsychotic) *1/15/22 [MEDICATION(S)] 0.005% drops 1 drop ophthalmic (eye) QHS (used to treat [CONDITION(S)]) *1/15/22 [MEDICATION(S)] 1% drops, suspension 1 drop ophthalmic (eye) daily (used to treat [CONDITION(S)]) *1/15/22 [MEDICATION(S)] 5 mg capsule 1 cap PO daily (used to treat high blood pressure) *1/15/22 [MEDICATION(S)] HCl 30 mg tablet 1 tab PO TID (antidepressant) *1/16/22 [MEDICATION(S)] 10 mg tablet 1 tab PO daily (used to treat Alzheimer's) *1/15/22 [MEDICATION(S)] 800 mg tablet 1 tab PO TID (anticonvulsant) *1/15/22 [MEDICATION(S)] 10 mg tablet 1 tab PO daily (used to treat confusion (dementia) related to Alzheimer's disease) *1/16/22 [MEDICATION(S)] 10 mg tablet 1 tab PO daily (used to lower cholesterol) Record review of a hand-written telephone order dated 1/14/22, written by LVN C, indicated Resident #1 was to have accuchecks (used to monitor blood sugar) AC and HS and was to receive [MEDICATION(S)] 10 units SQ every HS (used to control blood sugar). The order was never put into the electronic health record. Record review of nursing progress note dated 1/14/22 at 11:19 p.m., completed by LVN C, indicated Resident #1 arrived via ambulance and was nonverbal, alert, confused, had a [CONDITION(S)], had altered mental status, weakness, dementia, and metabolic encephalitis. Resident #1 had dark yellow urine, was incontinent to bowl and bladder and had Type 2 diabetes. Accuchecks AC and HS, Sliding scale [MEDICATION(S)] 10 units subQ every HS. He had multiple bruises on his knees and arms, he walked with assist, and was on room air. His family sent a lot of snacks in bags in his room. There was no documented physician notification of the admission or to confirm any medication orders. Record review of nursing progress note dated 1/16/22 at 1:10 a.m., completed by LVN C, indicated Resident #1's [MEDICATION(S)] insulin pen arrived, and she put it in the refrigerator. There was no documented evidence the resident was administered any [MEDICATION(S)]. Record review of Resident #1's blood sugar levels completed by LVN C in vital signs portion of the electronic record indicated: *1/14/22 11:17 p.m. 246 mg/dl, *1/15/22 8:26 p.m. 422 mg/dl, *1/16/22 5:21 a.m. 359 mg/dl, and *1/16/22 11:17 p.m. 597 mg/dl. (normal blood sugar after not eating for at least 8 hours should be less than 100 mg/dl and less than 140 mg/dl 2 hours after eating) There was no documented evidence of intervention or physician notification for the elevated blood sugar levels. Record review of Resident #1's January 2022 MAR/TAR indicated no medication administration or blood sugar checks on the 6:00 a.m. to 6:00 p.m. shift on 1/14/22, 1/15/22, or 1/16/22. Record review of nursing progress noted dated 1/15/22 at 8:43 p.m., completed by LVN C, indicated LVN C administered Resident #1 the following medications at 8:30 p.m.: [MEDICATION(S)] HCL 30 mg 1 PO at bedtime, Baby Aspirin 81 mg 1 PO daily, [MEDICATION(S)] 10 mg 1 PO daily, [MEDICATION(S)] 50 mg tablet 1 tablet PO daily. LVN C documented all other medications were held and would resume tomorrow (1/16/22). Record review of nursing progress note dated 1/16/22 at 4:38 a.m., completed by LVN C, indicated Resident #1's medications (from home) were at the nurse station in a big zip lock bag. Record review of nursing progress note dated 1/16/22 at 11:45 a.m., completed by LVN A indicated Resident #1 May have 02 at 2-3 L/MIN PRN for shortness of breath. There was no documentation of physician notification. There was no documentation of reason for the progress note. There was no additional documentation from LVN A for 1/16/22. Record review of nursing progress note dated 1/16/22 at 11:45 p.m., completed by LVN C, indicated Resident #1 was found on side of bed on his knees and hands with face down on the floor. Resident #1 was not responsive to his name or tapping on his shoulder. LVN C called for LVN A to assist Resident #1 to his bed. He did not respond when asked if he was in pain. Resident #1's carotid artery was faint. Resident #1's BP was 157/75, HR was 84, respirations were 20, blood sugar was 597, and O2 was not obtainable. Started Resident on 02 3L via nasal cannula. LVN C called 911 and his family member. Resident #1 had not received any medications on the night shift. Resident #1's (home) medications were in zip lock bag in the medication cart. The medications were brought to the facility by Resident #1's family member and needed to be returned to her. Resident #1's [MEDICATION(S)] pen was in the refrigerator. There was no documentation of physician notification for the elevated blood sugar, fall, unresponsiveness, or discharge to the hospital. During an interview on 1/26/22 at 3:32 p.m., LVN C said Resident #1 was admitted [DATE]. LVN C said when she reviewed Resident #1's discharge papers from the hospital there were no medication orders. She said she saw discharge papers to check his blood sugar AC and HS and give [MEDICATION(S)] 10 units Sub Q HS. She said she did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she wrote out a verbal order for [MEDICATION(S)] from the discharge paperwork. She said she did not call the physician for the order. She said she called the DON and the ADON and told them of Resident #1's high blood sugar and asked if the facility had a standard sliding scale. She was not aware of any facility policies regarding admissions. LVN C said the ADON told her not to worry because she would contact the NP. She said the ADON told her the facility did not have a standard sliding scale. LVN C said a nurse on 01/15/22 (she could not recall who the nurse was) found Resident #1's orders and wrote the orders up for Resident #1's routine medications and assumed she faxed them over to the pharmacy. She said there was not a fax machine on the COVID unit. LVN C said she called Resident #1's family member about his behaviors and told her no medications had been delivered to the facility. She said Resident #1's family member took Resident #1's medications to the facility on the evening of 1/15/22. She said Resident #1's family member said the Resident should receive the evening/night medications, so he would sleep. LVN C said she did not have orders in the computer to document the medications and did not document the medications on the MAR. She said she documented the medications she administered to Resident #1 in the nurse progress note. She said the only medication delivered to the facility was the [MEDICATION(S)] pen. She said the pen came in at 1:10 a.m. on 1/16/22 a.m. LVN C said she did not administer the medication because it was after the time parameter of HS. She said Resident #1 was scheduled to have 10 units of the [MEDICATION(S)] on 1/16/22 HS but she could not find the [MEDICATION(S)] pen in the refrigerator. She said she came on shift at 6:00 p.m. on 1/16/22 and at approximately 6:15 p.m. she found Resident #1 on his knees with his head on the floor next to his bed. LVN C said she called for the nurse who was leaving the COVID unit to assist her and they helped him back to bed. LVN C said she assessed him, and he had no injuries. She called the ADON and reported Resident #1 would not respond to stimuli and was directed to send Resident #1 to the hospital for evaluation and treatment. She said she did not notify the MD of his change of condition. She said she did not know who Resident #1's physician was. She said she did not notify Resident #1's physician of high blood sugars on 1/15/22 or 1/16/22. She said the DON and ADON told her they would call the physician or NP. Record review Resident #1's hospital record dated 01/16/22 indicated Resident #1 presents to the emergency department via EMS intubated after being found unresponsive on the ground with unknown down time. Per EMS nursing home staff could not tell them anything about when the last time they saw him. He was found on the ground at an unknown time last known normal and GCS was 3. Patient was intubated in route. Blood sugar 547. The glucose level in the emergency room read high indicating the blood sugar was over 600 mg/dl. The critical care not from the emergency room note indicated Direct patient care, Resuscitation, additional history, Interpretation lab/[NAME] (laboratory and radiology), Documentation, Phone consult with MD, Unstable/abnormal vital signs, Life threatening conditions, Multiple evaluations. Resident #1's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/25/22 at 4:04 p.m. MD E said he was not notified of any admissions on 1/14/22 involving Resident #1. He said he was never notified of Resident #1 being admitted or that he had elevated blood sugars. He was not aware Resident #1 had been sent to the hospital for a blood sugar of 597. MD E said that was a high blood sugar and should have had a sliding scale. MD E said it was easy to give an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . MD E said he was disappointed and the whole situation should not have happened. He said he was always available to the facility for the admissions. During an interview on 1/26/22 at 11:01 a.m., MD E said he was notified about pending admissions but was not always notified when the resident was physically admitted and should have been notified when they were admitted . He said diabetics usually had orders for sliding scale insulin. If the blood sugar was still not in control, then the attending physician must be notified for further orders. During an interview on 1/25/22 at 11:06 a.m., LVN A said she was called in to work the COVID unit on 1/15/22. She said she was not aware Resident #1 was a diabetic. She said he was alert but confused. LVN A said when a resident was admitted , orders should have been sent with the resident. She said if there were no orders, the admitting nurse should call the physician to obtain orders. She said the name of the physician should be in the electronic record. She said if the name of the physician was not available, the admitting nurse should have called someone in administration. LVN A said diabetics usually had sliding scale parameter for their blood sugars. She said if the blood sugar was above the parameters, the physician should be called. She said she would have called the physician, not the DON or ADON. She said the facility had insulin and other medications available in two emergency kits. She said she could not recall if she gave any medications to Resident #1. She said LVN C called her back in the COVID unit on 1/16/22 to assist Resident #1 from the floor. She said she last recalled seeing Resident #1 during the supper meal. She said he did not appear in distress. During an interview on 1/25/22 at 12:21 p.m., the ADON said the admitting nurse was responsible for putting orders in the electronic health record. She said a lot of times she would go back and check orders for new admissions. She said Resident #1 was admitted on a weekend, so she did not look at the admission. She said it was not her responsibility. She said she did not know if anyone was designated to be responsible for checking admissions for accuracy. She said she or the DON would usually look at admissions the following Monday. She said she did not receive any calls about Resident #1's medications. She said there was no system in place for admitting residents to ensure all staff were on the same page and knew what was needed for the resident prior to admission. During an interview on 1/25/22 at 1:59 p.m., RN B said the nurse who completed the admission was responsible for calling the physician and putting physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/25/22 at 12:57 p.m., the DON said she was not aware the physician had not been notified of the admission. She said the admitting nurse should have called to let MD E know the resident was admitted and confirm any orders. The DON said the ADON was responsible for auditing the charts after an admission, but she had not been monitoring to ensure admissions were being completed. She said there was not anyone auditing the charts for residents admitted on a Friday evening or weekend. The DON said she noticed the batch orders (standing orders) were not in the computer so she put Resident #1's standing orders in from home on 1/15/22. She said she did not call the facility to ask why Resident #1's medications were not in the computer. She said the nurse who wrote the telephone orders for Resident #1 should have put the orders into the computer when they were written. The DON said she received a call from the ADON on 1/16/22 saying Resident #1 was unresponsive and was being sent to the hospital. During an interview on 1/25/22 at 12:57 p.m., LVN D, a corporate nurse said LVN C did not notify the physician of Resident #1's admission or carry out orders when he was admitted . She said the resident had a high blood sugar and the physician should have been notified. During an interview on 1/25/22 at 3:47 p.m., the DON said she did not receive any calls from LVN C regarding physician notification or medication clarification. During an interview on 1/25/22 at 3:56 p.m., pharmacy technician S said Resident #1 was no longer active in their system. She said the only order they received from the facility was for the Resident #1's [MEDICATION(S)] insulin. She said the facility received the [MEDICATION(S)] on 1/15/22 at 11:57 p.m. During an interview on 1/25/22 at 4:41 p.m., LVN A said she wrote Resident #1's medications on a telephone order sheet and handed it to the ADON on 1/15/22. She assumed the ADON faxed the medication list to the pharmacy because there was not a fax machine on the COVID unit. She did not call the physician about Resident #1's medications because she assumed he had already been notified. She did not know the physician had not been notified of the admission. During an interview on 1/26/22 at 2:15 p.m., the Administrator said LVN C was not a new nurse. He said he was not aware LVN C did not call Resident #1's physician for a change of condition. He said he was not aware residents were admitted and the physician/medical director was not made aware. He said the admitting nurse should have followed policy and notified the physician of resident admission and clarified medications. During an interview on 1/25/22 at 1:46 p.m. Resident #1's family member said Resident #1 was discharged from the hospital to a different facility She said LVN C called her and asked for a list of Resident #1's medications but she did not have it. She said she did not know Resident #1 was on insulin. Record review of the facility's Nursing Policy and Procedures -Admitting a Resident-General Policy dated 06/19 indicated .Residents are admitted on ly upon the written order of the attending physician. Record review of the facility's Nursing Policy and Procedures-Change in Condition Communication dated 06/19 indicated .2. Notify the physician of the change in medical condition.3. All attempts to notify the physicians will be thoroughly documented in the patient's/resident's medical record. The Administrator was notified on 01/26/22 at 2:00 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 01/26/22 at 2:07 p.m. The facility's Plan of Removal was accepted on 01/27/22 at 9:54 a.m. and included: On January 26, 2022 the facility re-educated the nursing staff at [facility name] regarding, notification to physician on admission of a patient and immediately when there is a change of condition or a need to alter treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Moving forward, no resident will be admitted without physician orders. Those orders will be verified by admitting nurse and the physician or physician NP notified via phone call of orders prior to admitting resident. This will be confirmed by either the DON, ADON and or designee. After accepting a new resident, a checklist that includes but is not limited to: admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident charts will be audited for appropriate orders by existing corporate nursing staff and ensure physicians have been notified of any changes necessary. This audit has already begun and will continue on all residents in house. Audit will be completed by 1/27/22. The Facility also re-educated nursing staff (licensed nurses which includes LVN's and RN's) regarding notification to the Physician immediately for change in conditions and vitals out of normal range. Existing corporate nursing staff/administrator and or designee will educate facility nursing staff. Staff not present for in person education will be educated via phone calls or they must be educated prior to working their next scheduled shift. Staff have been educated by existing corporate nursing staff to ensure that Physician/NPs will be notified immediately of any FSBS in the range outside of the NP's protocols such as if the FSBS is above 400 per specific resident. The facility created a Quality assurance tool to be done 5 times a week for 12 weeks to monitor Physician notification, as part of the daily clinical meeting. The administrator and or designee will bring the QA tools to each morning meeting and to the monthly QAPI meeting to ensure compliance. This will be ongoing for a period of 12 weeks and routinely spot checked each week after the 12-week period to ensure continued compliance. The facility also created another Quality assurance tool to be done 5 times a week for 12 weeks to monitor admission of residents to ensure, Physician notification, Orders are verified and in the clinical record, Medications were ordered to the pharmacy. Quality assurance tools were started on 1/26/22. On 01/27/22 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Interviews conducted with 1 RN and 5 LVNs indicated they were able to correctly state the protocol for notification of the physician on admission of a patient and immediately when there was a change of condition or a need to alter treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] The facility had suspended admissions to the facility pending the end of the current COVID-19 outbreak. Record review of the facility's admission checklist indicated the checklist included physician notification, medication order verification, and submission of medication orders to the pharmacy. Record review of staff training dated 1/26/22 included physician notification, admission process, physician order [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation on 1/27/22 at 1:00 p.m. indicated copies of the admission checklist were available at the nurse station and on 3 of 3 medication carts to ensure compliance. Record review of the facility's chart audit dated 1/27/22 indicated the facility had completed 100% chart audit and notified the physicians of any changes as required. The facility had existing corporate nursing staff educate staff to ensure that Physician/NPs would be notified immediately of any FSBS in the range outside of the NP's protocols such as if the FSBS is above 400 per specific resident and admissions. Record review of the facility created quality assurance tool indicated it was to be completed 5 times a week for 12 weeks to monitor physician notification, as part of the daily clinical meeting. Record review of second quality assurance tool indicated it was to be completed 5 times a week for 12 weeks to monitor admission of residents to ensure, physician notification, order verification and entered in the clinical record, and medications were sent to the pharmacy (and received by the pharmacy). On 1/27/22 at 5:42 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview, and record review the facility failed to have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident #1) The facility failed to have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's hospital discharge records indicated the resident was a diabetic and required sliding scale insulin. Resident #1's blood sugars were above 246 mg/dl on four occasions. Resident #1's blood sugar on 1/16/22 was 597 mg/dl. He was discharged to the hospital on 1/16/22 unresponsive. Resident #1 required intubation (tube placed into the trachea to maintain an open airway) in the ambulance on the way to the emergency room . An Immediate Jeopardy (IJ) was identified at 2:00 p.m. on 01/26/22. While the IJ was removed on 01/27/22, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for not receiving appropriate care and treatment services resulting in hospitalization Findings included: Record review of Resident #1's face sheet indicated he was [AGE] years old and was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was discharged to the hospital on 1/16/22. Record review of the electronic health record indicated there was no available MDS for review due to Resident #1's admission status. Record review of Resident #1's medical record indicated there were no orders for Resident #1's immediate care and for medications. Review of Resident #1's hospital discharge packet faxed to the facility on [DATE] indicated there was no insulin or other diabetes medications included with the active medication list. Record review of Resident #1's cumulative physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] *1/15/22 [MEDICATION(S)] 5 mg tablet 1tab PO QHS (a sedative) *1/15/22 [MEDICATION(S)] 50 mg 1tab PO daily (antipsychotic) *1/15/22 [MEDICATION(S)] 0.005% drops 1 drop ophthalmic (eye) QHS (used to treat [CONDITION(S)]) *1/15/22 [MEDICATION(S)] 1% drops, suspension 1 drop ophthalmic (eye) daily (used to treat [CONDITION(S)]) *1/15/22 [MEDICATION(S)] 5 mg capsule 1 cap PO daily (used to treat high blood pressure) *1/15/22 [MEDICATION(S)] HCl 30 mg tablet 1tab PO TID (antidepressant) *1/16/22 [MEDICATION(S)] 10 mg tablet 1tab PO daily (used to treat Alzheimer's) *1/15/22 [MEDICATION(S)] 800 mg tablet 1tab PO TID (anticonvulsant) *1/15/22 [MEDICATION(S)] 10 mg tablet 1tab PO daily (used to treat confusion (dementia) related to Alzheimer's disease) *1/16/22 [MEDICATION(S)] 10 mg tablet 1tab PO daily (used to lower cholesterol) Record review of a hand-written telephone order dated 1/14/22 written by LVN C indicated Resident #1 was to have accuchecks (used to monitor blood sugar) AC and HS and was to receive [MEDICATION(S)] 10 units SQ every HS (used to control blood sugar). The order was never put into the electronic health record. Record review of Resident #1's baseline care plan dated 1/14/22 indicated Resident #1 was a diabetic and his medications included insulin. Record review of nursing progress note dated 1/14/22 at 11:19 p.m., completed by LVN C, indicated Resident #1 arrived via ambulance and was nonverbal, alert, confused, had a [CONDITION(S)], had altered mental status, weakness, dementia, and metabolic encephalitis. Resident #1 had dark yellow urine, was incontinent to bowl and bladder and had Type 2 diabetes. Accuchecks AC and HS, Sliding scale [MEDICATION(S)] 10 units subQ every HS. He had multiple bruises on his knees and arms, he walked with assist, and was on room air. His family sent a lot of snacks in bags in his room. There was no documented physician notification of the admission or to confirm any medication orders. Record review of nursing progress note dated 1/16/22 at 1:10 a.m., completed by LVN C, indicated Resident #1's [MEDICATION(S)] insulin pen arrived. It is in the refrigerator. There was no documented evidence the resident was administered any [MEDICATION(S)] insulin. Record review of Resident #1's blood sugar levels completed by LVN C in vital signs portion of the electronic record indicated: *1/14/22 11:17 p.m. 246 mg/dl, *1/15/22 8:26 p.m. 422 mg/dl, *1/16/22 5:21 a.m. 359 mg/dl, and *1/16/22 11:17 p.m. 597 mg/dl. (normal blood sugar after not eating for at least 8 hours should be less than 100 mg/dl and less than 140 mg/dl 2 hours after eating) Record review of nursing progress note dated 1/16/22 at 11:45 p.m., completed by LVN C, indicated Resident #1 was found on side of bed on his knees and hands with face down on the floor. Resident #1 was not responsive to his name or tapping on his shoulder. LVN C called for LVN A to assist Resident #1 to his bed. He did not respond when asked if he was in pain. Resident #1's carotid artery was faint. Resident #1's BP was 157/75, HR was 84, respirations were 20, blood sugar was 597, and O2 was not obtainable. Started Resident on 02 3L via nasal cannula. LVN C called 911 and his daughter. Resident #1 had not received any medications on the night shift. Resident #1's (home) medications were in zip lock bag in the medication cart. The medications were brought to the facility by Resident #1's daughter and needed to be returned to her. Resident #1's [MEDICATION(S)] pen was in the refrigerator. There was no documentation of physician notification for the elevated blood sugar, fall, unresponsiveness, or discharge to the hospital. During an interview on 1/26/22 at 3:32 p.m., LVN C said Resident #1 was admitted [DATE]. LVN C said when she reviewed Resident #1's discharge papers from the hospital there were no medication orders. She said she saw discharge papers to check his blood sugar AC and HS and give [MEDICATION(S)] 10 units Sub Q HS. She said she did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she wrote out a verbal order for [MEDICATION(S)] from the discharge paperwork. She said she did not call the physician for any orders. LVN C said she did not know what the facility's policy was for admitting a resident. She said a nurse on 01/15/22 (she could not recall who the nurse was) found Resident #1's orders and wrote the orders up for Resident #1's routine medications and assumed she faxed them over to the pharmacy. She said there was not a fax machine on the COVID unit. LVN C said she called Resident #1's family member about his behaviors and told her no medications had been delivered to the facility. She said Resident #1's family member took Resident #1's medications to the facility on the evening of 1/15/22. She said Resident #1's family member said the Resident should receive the evening/night medications, so he would sleep. LVN C said she did not have orders in the computer to document the medications and did not document the medications on the MAR. She said she documented the few medications she administered to Resident #1 in the nurse progress note. She said the only medication delivered to the facility was the [MEDICATION(S)] pen. She said the pen came in at 1:10 a.m. on 1/16/22 a.m. LVN C said she did not administer the medication because it was after the time parameter of HS. She said Resident #1 was scheduled to have 10 units of the [MEDICATION(S)] on 1/16/22 at HS but she could not find the [MEDICATION(S)] pen in the refrigerator. She said she came on shift at 6:00 p.m. on 1/16/22 and at approximately 6:15 p.m. she found Resident #1 on his knees with his head on the floor adjacent to his bed. LVN C said she called for the nurse who was leaving the COVID unit to assist her and they helped him back to bed. She called the ADON and reported Resident #1 would not respond to stimuli and was directed to send Resident #1 to the hospital for evaluation and treatment. She said she did not notify the MD of his change of condition. She said she did not know who Resident #1's physician was. She said she did not notify Resident #1's physician of high blood sugars on 1/15/22 or 1/16/22. She said the DON and ADON told her they would call the physician or NP. Record review Resident #1's hospital record dated 01/16/22 indicated Resident #1 presents to the emergency department via EMS intubated after being found unresponsive on the ground with unknown down time. Per EMS nursing home staff could not tell them anything about when the last time they saw him. He was found on the ground at an unknown time last known normal and GCS was 3. Patient was intubated in route. Blood sugar 547.The glucose level in the emergency room read high indicating the blood sugar was over 600 mg/dl. The critical care not from the emergency room note indicated Direct patient care, Resuscitation, additional history, Interpretation lab/[NAME] (laboratory and radiology), Documentation, Phone consult with MD, Unstable/abnormal vital signs, Life threatening conditions, Multiple evaluations. Resident #1's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/25/22 at 4:04 p.m. MD E said he was not notified of any admissions on 1/14/22 involving Resident #1. He said he was never notified of Resident #1 being admitted or that he had elevated blood sugars. He said he should have been notified for both the admission and the elevated blood sugar. He was not aware Resident #1 had been sent to the hospital for a blood sugar of 597. MD E said that was a high blood sugar. He said he would have ordered a sliding scale for the resident. MD E said it was easy to give an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He said he or an on-call person was always available to the facility for the admissions. During an interview on 1/25/22 at 11:06 a.m., LVN A said when a resident was admitted , orders should have been sent with the resident. She said if there were no orders, the admitting nurse should call the physician to obtain orders. She said the name of the physician should be in the electronic record prior to being admitted . She said if the name of the physician was not available, the admitting nurse should have called someone in administration. LVN A said diabetics usually had sliding scale parameter for their blood sugars. She said if the blood sugar was above the parameters, the physician should be called. She said she would have called the physician, not the DON or ADON. She said the facility had insulin and other medications available in two emergency kits. During an interview on 1/25/22 at 12:21 p.m., the ADON said the admitting nurse was responsible for putting orders in the computer and notifying the physician of the admission. She said a lot of times she would go back and check orders for new admissions. She said Resident #1 was admitted on a weekend, so she did not look at the admission. She said it was not her responsibility. She said she did not know who was responsible for checking admissions for accuracy. She said she or the DON would usually look at admissions the following Monday to ensure all orders were in the computer and the admission was complete. She said she did not receive any calls about Resident #1's medications. She said there was no system in place for admitting residents to ensure all staff were on the same page and knew what was needed for the resident prior to admission. During an interview on 1/25/22 at 1:59 p.m., RN B said the nurse who completed the admission was responsible for calling the physician and putting physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she was not aware of any system to ensure admissions had been completed. During an interview on 1/25/22 at 12:57 p.m., the DON said she was not aware the physician had not been notified of the admission. She said the admitting nurse should have called to let MD E know the Resident #1 was admitted and confirm any orders. She said the ADON was responsible for auditing the charts after an admission, but she had not been monitoring to ensure the admissions were complete. She said there had not been anyone auditing the charts for residents admitted on a Friday evenings or weekends. The DON said she noticed the batch orders (standing orders) were not in the computer so she put Resident #1's standing orders in from home on 1/15/22. She said she did not call the facility to ask why Resident #1's medications were not in the computer. She said the nurse who wrote the telephone orders for Resident #1 should have put the orders into the computer when they were written. The DON said she received a call from the ADON on 1/16/22 saying Resident #1 was unresponsive and was being sent to the hospital. During an interview on 1/25/22 at 12:57 p.m., LVN D, a corporate nurse, said LVN C did not notify the physician or carry out orders for Resident #1 when he was admitted . She said the resident had a high blood sugar and the physician should have been notified. During an interview on 1/25/22 at 3:47 p.m., the DON said she did not receive any calls from LVN C regarding physician notification or medication clarification. During an interview on 1/25/22 at 3:56 p.m., pharmacy technician S said Resident #1 was no longer active in their system. She said the only order they received from the facility was for the Resident #1's [MEDICATION(S)] insulin. She said the facility received the [MEDICATION(S)] on 1/15/22 at 11:57 p.m. During an interview on 1/25/22 at 4:41 p.m., LVN A said she wrote Resident #1's medications on a telephone order sheet and handed it to the ADON on 1/15/22. She did not call the physician about the medications. She assumed the physician was notified when the resident was admitted . She was not aware the physician had not been notified of the admission. During an interview on 1/26/22 at 2:15 p.m., the administrator said LVN C was not a new nurse. He said he was not aware LVN C did not call Resident #1's physician for a change of condition. He said he was not aware residents were admitted and the physician/medical director was not made aware. He said the admitting nurse should have followed policy and notified the physician of resident admission and clarified medications. During an interview on 1/25/22 at 1:46 p.m. Resident #1's family member said Resident #1 was discharged from the hospital to a different facility. She said LVN C called her and asked for a list of Resident #1's medications but she did not have it. She said she did not know Resident #1 was on insulin in the hospital. During an interview on 1/26/22 at 11:01 a.m., MD E said he was notified about pending admissions but did not always get notified when the resident was physically admitted to give or confirm orders. He said diabetics usually had orders for sliding scale insulin. If the blood sugar was still not in control, then the attending physician must be notified for further orders. Record review of the facility's Admitting A Resident - General Policy revised 6/2019 indicated Residents are admitted on ly upon the written order of the attending physician. The Resident and/or responsible individual(s) will be assisted in selecting a physician's service, if necessary. Emergency admission may be made when necessary. All aspects of an individual's care are carefully considered during admission. Prior to admission, an assessment is made of the Resident's needs by reviewing a clinical record. The following information shall be made available to the Facility: History and Physical: Medical findings; Diagnosis(es); Allergies (if known); Summary of course of treatment from discharging Facility; Orders from a physician, for immediate care of the Resident; The Administrator was notified on 01/26/22 at 2:00 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 01/26/22 at 2:07 p.m. The facility's Plan of Removal was accepted on 01/27/22 at 9:54 a.m. and included: On January 26, 2022 the facility re-educated the nursing staff at [facility name] regarding, notification to physician on admission of a patient and immediately when there is a change of condition or a need to alter treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Moving forward, no resident will be admitted without physician orders. Those orders will be verified by admitting nurse and the physician or physician NP notified via phone call of orders prior to admitting resident. This will be confirmed by either the DON, ADON and or designee. After accepting a new resident, a checklist that includes but is not limited to: admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident charts will be audited for appropriate orders by existing corporate nursing staff and ensure physicians have been notified of any changes necessary. This audit has already begun and will continue on all residents in house. Audit will be completed by 1/27/22. The Facility also re-educated nursing staff (licensed nurses which includes LVN's and RN's) regarding notification to the Physician immediately for change in conditions and vitals out of normal range. Existing corporate nursing staff/administrator and or designee will educate facility nursing staff. Staff not present for in person education will be educated via phone calls or they must be educated prior to working their next scheduled shift. Staff have been educated by existing corporate nursing staff to ensure that Physician/NPs will be notified immediately of any FSBS in the range outside of the NP's protocols such as if the FSBS is above 400 per specific resident. The facility created a Quality assurance tool to be done 5 times a week for 12 weeks to monitor Physician notification, as part of the daily clinical meeting. The administrator and or designee will bring the QA tools to each morning meeting and to the monthly QAPI meeting to ensure compliance. This will be ongoing for a period of 12 weeks and routinely spot checked each week after the 12-week period to ensure continued compliance. The facility also created another Quality assurance tool to be done 5 times a week for 12 weeks to monitor admission of residents to ensure, Physician notification, Orders are verified and in the clinical record, Medications were ordered to the pharmacy. Quality assurance tools were started on 1/26/22. On 01/27/22 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Interviews conducted with 1 RN and 5 LVNs indicated they were able to correctly state the protocol for notification of the physician on admission of a patient and immediately when there was a change of condition or a need to alter treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] The facility had suspended admissions to the facility pending the end of the current COVID-19 outbreak. Record review of the facility's admission checklist indicated the checklist included physician notification, medication order verification, and submission of medication orders to the pharmacy. Record review of staff training included physician notification, admission process, physician order [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation on 1/27/22 at 1:00 p.m. indicated copies of the admission checklist were available at the nurse station and on 3 of 3 medication carts to ensure compliance. Record review of the facility's chart audit dated 1/27/22 indicated the facility had completed 100% chart audit and notified the physicians of any changes as required. The facility had existing corporate nursing staff to ensure that Physician/NPs will be notified immediately of any FSBS in the range outside of the NP's protocols such as if the FSBS is above 400 per specific resident. Record review of the facility created quality assurance tool indicated it was to be completed 5 times a week for 12 weeks to monitor physician notification, as part of the daily clinical meeting. Record review of second quality assurance tool indicated it was to be completed 5 times a week for 12 weeks to monitor admission of residents to ensure, physician notification, order verification and entered in the clinical record, and medications were sent to the pharmacy (and received by the pharmacy). On 1/27/22 at 5:42 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 4 residents reviewed for quality of care. (Resident #1) The facility failed to ensure Resident #1, a new admission with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not receive any intervention when the residents blood sugars were above 246 mg/dl on four occasions. Resident #1's blood sugar on 1/16/22 was 597 mg/dl. He was discharged to the hospital on 1/16/22 unresponsive. Resident #1 required intubation (tube placed into the trachea to maintain an open airway) in the ambulance on the way to the emergency room . On 01/26/22 at 2:00 p.m. an Immediate Jeopardy (IJ) was identified While the IJ was removed on 01/27/22, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk for not receiving appropriate care and treatment services to meet resident needs. Findings included: Record review of Resident #1's face sheet indicated he was [AGE] years old and was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was discharged to the hospital on 1/16/22. Record review of the medical record indicated there was no available MDS for review due to Resident #1's admission status. Record review of Resident #1's medical record indicated no orders to admit and treat Resident #1 including medications. Review of Resident #1's hospital discharge packet faxed to the facility on [DATE] indicated there was no insulin or other diabetes medications included with the active medication list. Record review of Resident #1's cumulative physician orders, dated 1/25/22, indicated the following medications were added in the electronic medical record on 1/15/22 and 1/16/22: *1/15/22 [MEDICATION(S)] 5 mg tablet 1tab PO QHS (a sedative) *1/15/22 [MEDICATION(S)] 50 mg 1tab PO daily (antipsychotic) *1/15/22 [MEDICATION(S)] 0.005% drops 1 drop ophthalmic (eye) QHS (used to treat [CONDITION(S)]) *1/15/22 [MEDICATION(S)] 1% drops, suspension 1 drop ophthalmic (eye) daily (used to treat [CONDITION(S)]) *1/15/22 [MEDICATION(S)] 5 mg capsule 1 cap PO daily (used to treat high blood pressure) *1/15/22 [MEDICATION(S)] HCl 30 mg tablet 1tab PO TID (antidepressant) *1/16/22 [MEDICATION(S)] 10 mg tablet 1tab PO daily (used to treat Alzheimer's) *1/15/22 [MEDICATION(S)] 800 mg tablet 1tab PO TID (anticonvulsant) *1/15/22 [MEDICATION(S)] 10 mg tablet 1tab PO daily (used to treat confusion (dementia) related to Alzheimer's disease) *1/16/22 [MEDICATION(S)] 10 mg tablet 1tab PO daily (used to lower cholesterol) Record review of a hand-written telephone order dated 1/14/22, written by LVN C, indicated Resident #1 was to have accuchecks (used to monitor blood sugar) AC and HS and was to receive [MEDICATION(S)] 10 units SQ every HS (used to control blood sugar). The order was never put into the electronic medical record. Record review of Resident #1's baseline care plan, dated 1/14/22, indicated Resident #1 was a diabetic, his medications included insulin, and his medication list had not been reconciled. Record review of nursing progress note, dated 1/14/22 at 11:19 p.m., completed by LVN C, indicated Resident #1 arrived via ambulance and was nonverbal, alert, confused, had a [CONDITION(S)], had altered mental status, weakness, dementia, and metabolic encephalitis. Resident #1 had dark yellow urine, was incontinent to bowl and bladder and had Type 2 diabetes. Accuchecks AC and HS, Sliding scale [MEDICATION(S)] 10 units subQ every HS. He had multiple bruises on his knees and arms, he walked with assist, and was on room air. His family sent a lot of snacks in bags in his room. There was no documented physician notification of the admission or to confirm any medication orders. Record review of nursing progress note, dated 1/16/22 at 1:10 a.m., completed by LVN C, indicated Resident #1's [MEDICATION(S)] insulin pen arrived. It is in the refrigerator. There was no documented evidence the resident was administered any [MEDICATION(S)] insulin. Record review of Resident #1's blood sugar levels, completed by LVN C, in the vital signs portion of the electronic record indicated: *1/14/22 11:17 p.m. 246 mg/dl, *1/15/22 8:26 p.m. 422 mg/dl, *1/16/22 5:21 a.m. 359 mg/dl, and *1/16/22 11:17 p.m. 597 mg/dl. (normal blood sugar after not eating for at least 8 hours should be less than 100 mg/dl and less than 140 mg/dl 2 hours after eating) Record review of nursing progress note, dated 1/16/22 at 11:45 p.m., completed by LVN C, indicated Resident #1 was found on side of bed on his knees and hands with face down on the floor. Resident #1 was not responsive to his name or tapping on his shoulder. LVN C called for LVN A to assist Resident #1 to his bed. He did not respond when asked if he was in pain. Resident #1's carotid artery was faint. Resident #1's BP was 157/75, HR was 84, respirations were 20, blood sugar was 597, and O2 was not obtainable. Started Resident on 02 3L via nasal cannula. LVN C called 911 and his daughter. Resident #1 had not received any medications on the night shift. Resident #1's (home) medications were in zip lock bag in the medication cart. The medications were brought to the facility by Resident #1's daughter and needed to be returned to her. Resident #1's [MEDICATION(S)] pen was in the refrigerator. There was no documentation of physician notification for the elevated blood sugar, fall, unresponsiveness, or discharge to the hospital. During an interview on 1/26/22 at 3:32 p.m., LVN C said Resident #1 was admitted [DATE]. She said he was confused and very busy (up and in and out of other rooms). LVN C said when she reviewed Resident #1's discharge papers from the hospital there were no medication orders. She said she saw discharge papers to check his blood sugar AC and HS and give [MEDICATION(S)] 10 units Sub Q HS. She said she did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she wrote out a verbal order for [MEDICATION(S)] from the discharge paperwork. She said she did not call the physician for any orders. She could not remember why she did not call the physician. She said she was not aware of the facility's admission policy. She said a nurse on 01/15/22 (she could not recall who the nurse was) found Resident #1's orders and wrote the orders up for Resident #1's routine medications and assumed she faxed them over to the pharmacy. She said she was on the COVID unit and did not have access to a fax machine. LVN C said she called Resident #1's family member about his behaviors and told her no medications had been delivered to the facility. She said Resident #1's family member took Resident #1's medications to the facility on the evening of 1/15/22. She said Resident #1's family member said the Resident should receive the evening/night medications, so he would sleep. LVN C said she did not have orders in the computer to document the medications and did not document the medications on the MAR. She said she documented the few medications she administered to Resident #1 in the nurse progress note. She said the only medication delivered to the facility was the [MEDICATION(S)] pen. She said the pen came in at 1:10 a.m. on 1/16/22 a.m. LVN C said she did not administer the medication because it was after the time parameter of HS. She did not call the physician to ask if ok to administer the [MEDICATION(S)] when the medication arrived. She said on 1/16/22 Resident #1 was scheduled to have 10 units of the [MEDICATION(S)] at HS but she could not find the [MEDICATION(S)] pen in the refrigerator. She said she did not call or ask anyone about the medication. She said she came on shift at 6:00 p.m. on 1/16/22 and at approximately 6:15 p.m. she found Resident #1 on his knees with his head on the floor adjacent to his bed. LVN C said she called for the nurse who was leaving the COVID-19 unit to assist her and they helped him back to bed. LVN C said she assessed him and he had no injuries. She called the ADON and reported Resident #1 would not respond to stimuli and was directed to send Resident #1 to the hospital for evaluation and treatment. She said she did not notify the MD of his change of condition. She said she did not know who Resident #1's physician was. She said she did not notify Resident #1's physician of high blood sugars on 1/15/22 or 1/16/22. She said the DON and ADON told her they would call the physician or NP. Record review Resident #1's hospital record dated 01/16/22 indicated Resident #1 presents to the emergency department via EMS intubated after being found unresponsive on the ground with unknown down time. Per EMS nursing home staff could not tell them anything about when the last time they saw him. He was found on the ground at an unknown time last known normal and GCS was 3. Patient was intubated in route. Blood sugar 547. The glucose level in the emergency room read high indicating the blood sugar was over 600 mg/dl. The critical care note from the emergency room note indicated Direct patient care, Resuscitation, additional history, Interpretation lab/[NAME] (laboratory and radiology), Documentation, Phone consult with MD, Unstable/abnormal vital signs, Life threatening conditions, Multiple evaluations. Resident #1's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/25/22 at 4:04 p.m. MD E said he was not notified of any admissions on 1/14/22 involving Resident #1. He said he was never notified of Resident #1 being admitted or that he had elevated blood sugars. He was not aware Resident #1 had been sent to the hospital for a blood sugar of 597. MD E said that was a high blood sugar and should have had a sliding scale. MD E said it was easy to give an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . MD E said he was disappointed and the whole situation should not have happened. He said he was always available to the facility for the admissions. During an interview on 1/25/22 at 11:06 a.m., LVN A said when a resident was admitted , orders should have been sent with the resident. She said if there were no orders, the admitting nurse should call the physician to obtain orders. She said the name of the physician should be in the electronic record. She said if the name of the physician was not available, the admitting nurse should have called someone in administration. LVN A said diabetics usually had sliding scale parameters for their blood sugars. She said if the blood sugar was above the parameters, the physician should be called. She said she would have called the physician, not the DON or ADON. She said the facility had insulin and other medications available in two emergency kits. During an interview on 1/25/22 at 12:21 p.m., the ADON said the admitting nurse was responsible for putting orders in the computer and notifying the physician of the admission. She said a lot of times she would go back and check orders for new admissions. She said Resident #1 was admitted on a weekend, so she did not look at the admission. She said it was not her responsibility and did not know who was responsible for ensuring admissions on the weekend were complete. She said she or the DON would usually look at admissions the following Monday to ensure all orders were in the computer and the admission was complete. She said she did not receive any calls about Resident #1's medications. She said there was no system in place for admitting residents to ensure all staff were on the same page and knew what was needed for the resident prior to admission. During an interview on 1/25/22 at 1:59 p.m., RN B said the nurse who completed the admission was responsible for calling the physician and putting physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/25/22 at 12:57 p.m., the DON said she was not aware the physician had not been notified of the admission. She said the admitting nurse should have called to let MD E know the Resident #1 was admitted and confirm any orders. She said the ADON was responsible for auditing the charts after an admission. She said there had not been anyone auditing the charts for residents admitted on a Friday evenings or weekends. The DON said she noticed the batch orders (standing orders) were not in the computer so she put Resident #1's standing orders in from home on 1/15/22. She said she did not call the facility to ask why Resident #1's medications were not in the computer. She said the nurse who wrote the telephone orders for Resident #1 should have put the orders into the computer when they were written. The DON said she received a call from the ADON on 1/16/22 saying Resident #1 was unresponsive and was being sent to the hospital. During an interview on 1/25/22 at 12:57 p.m., LVN D, a corporate nurse, said LVN C did not notify the physician or carry out orders for Resident #1 when he was admitted . She said the resident had a high blood sugar and the physician should have been notified. During an interview on 1/25/22 at 3:47 p.m., the DON said she did not receive any calls from LVN C regarding physician notification or medication clarification. During an interview on 1/25/22 at 3:56 p.m., Pharmacy Technician S said Resident #1 was no longer active in their system. She said the only order they received from the facility was for the Resident #1's [MEDICATION(S)] insulin. She said the facility received the [MEDICATION(S)] on 1/15/22 at 11:57 p.m. During an interview on 1/25/22 at 4:41 p.m., LVN A said she wrote Resident #1's medications on a telephone order sheet and handed it to the ADON on 1/15/22. She did not call the physician about the medications. She was not aware the physician had not been notified of the admission. During an interview on 1/26/22 at 2:15 p.m., the Administrator said LVN C was not a new nurse. He said she told him during her interview she knew how to navigate PCC, the electronic record system utilized by the facility. He said she felt quite comfortable with the system and had no questions when offered the position to work on the COVID-19 unit. He said he was not aware LVN C did not call Resident #1's physician for a change of condition. He said he was not aware residents were admitted and the physician/medical director was not made aware. He said the admitting nurse should have followed policy and notified the physician of resident admission and clarified medications. During an interview on 1/25/22 at 1:46 p.m. Resident #1's family member said Resident #1 was discharged from the hospital to a different facility. She said LVN C called her and asked for a list of Resident #1's medications but she did not have it. She said she did not know Resident #1 was on insulin in the hospital. During an interview on 1/26/22 at 11:01 a.m., MD E said he was notified about pending admissions but did not always get notified when the resident was physically admitted and should be notified when they were admitted . He said diabetics usually had orders for sliding scale insulin. If the blood sugar was still not in control, then the attending physician must be notified for further orders. Record review of the facility's Admitting A Resident - General Policy revised 6/2019 indicated Residents are admitted on ly upon the written order of the attending physician. The Resident and/or responsible individual(s) will be assisted in selecting a physician's service, if necessary. Emergency admission may be made when necessary. All aspects of an individual's care are carefully considered during admission. Prior to admission, an assessment is made of the Resident's needs by reviewing a clinical record. The following information shall be made available to the Facility: History and Physical: Medical findings; Diagnosis(es); Allergies (if known); Summary of course of treatment from discharging Facility; Orders from a physician, for immediate care of the Resident; Record review of the facility's Nursing Policy and Procedures-Change in Condition Communication dated 06/19 indicated .2. Notify the physician of the change in medical condition.3. All attempts to notify the physicians will be thoroughly documented in the patient's/resident's medical record. This was determined to be an Immediate Jeopardy (IJ) on 01/26/22 at 2:00 p.m. The Administrator was provided the Immediate Jeopardy template on 01/26/22 at 2:07 p.m. The facility's Plan of Removal was accepted on 01/27/22 at 9:54 a.m. and included: On January 26, 2022 the facility re-educated the nursing staff at [facility name] regarding, notification to physician on admission of a patient and immediately when there is a change of condition or a need to alter treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Moving forward, no resident will be admitted without physician orders. Those orders will be verified by admitting nurse and the physician or physician NP notified via phone call of orders prior to admitting resident. This will be confirmed by either the DON, ADON and or designee. After accepting a new resident, a checklist that includes but is not limited to: admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident charts will be audited for appropriate orders by existing corporate nursing staff and ensure physicians have been notified of any changes necessary. This audit has already begun and will continue on all residents in house. Audit will be completed by 1/27/22. The Facility also re-educated nursing staff (licensed nurses which includes LVN's and RN's) regarding notification to the Physician immediately for change in conditions and vitals out of normal range. Existing corporate nursing staff/administrator and or designee will educate facility nursing staff. Staff not present for in person education will be educated via phone calls or they must be educated prior to working their next scheduled shift. Staff have been educated by existing corporate nursing staff to ensure that Physician/NPs will be notified immediately of any FSBS in the range outside of the NP's protocols such as if the FSBS is above 400 per specific resident. The facility created a Quality assurance tool to be done 5 times a week for 12 weeks to monitor Physician notification, as part of the daily clinical meeting. The administrator and or designee will bring the QA tools to each morning meeting and to the monthly QAPI meeting to ensure compliance. This will be ongoing for a period of 12 weeks and routinely spot checked each week after the 12-week period to ensure continued compliance. The facility also created another Quality assurance tool to be done 5 times a week for 12 weeks to monitor admission of residents to ensure, Physician notification, Orders are verified and in the clinical record, Medications were ordered to the pharmacy. Quality assurance tools were started on 1/26/22. On 01/27/22 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Interviews conducted with 1 RN and 5 LVNs indicated they were able to correctly state the protocol for notification of the physician on admission of a patient and immediately when there was a change of condition or a need to alter treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] The facility had suspended admissions to the facility pending the end of the current COVID-19 outbreak. Record review of the facility's admission checklist indicated the checklist included physician notification, medication order verification, and submission of medication orders to the pharmacy. Record review of staff training dated 1/26/22 included physician notification, admission process, physician order [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation on 1/27/22 at 1:00 p.m. indicated copies of the admission checklist were available at the nurse station and on 3 of 3 medication carts to ensure compliance. Record review of the facility's chart audit dated 1/27/22 indicated the facility had completed 100% chart audit and notified the physicians of any changes as required. The facility had existing corporate nursing staff to ensure that Physician/NPs will be notified immediately of any FSBS in the range outside of the NP's protocols such as if the FSBS is above 400 per specific resident. Record review of the facility created quality assurance tool indicated it was to be completed 5 times a week for 12 weeks to monitor physician notification, as part of the daily clinical meeting. Record review of second quality assurance tool indicated it was to be completed 5 times a week for 12 weeks to monitor admission of residents to ensure, physician notification, order verification and entered in the clinical record, and medications were sent to the pharmacy (and received by the pharmacy). On 1/27/22 at 5:42 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving dispensing and administering of medications for 2 of 2 residents reviewed for pharmacy services (Resident #s 1 and 2). The facility failed to verify with the physician, order and administer medications for Resident #1 who was admitted on [DATE]. Resident #1's hospital discharge records indicated the resident was a diabetic and required sliding scale insulin. Resident #1's blood sugar on 1/16/22 was 597 mg/dl. He was discharged to the hospital on 1/16/22 unresponsive. Resident #1 required intubation (tube placed into the trachea to maintain an open airway) in the ambulance on the way to the emergency room . The facility failed to ensure medications were ordered and administered as ordered. Resident #2 was admitted on [DATE]. Her medications were not verified by the physician or ordered from the pharmacy. Resident #2 was administered Tylenol #4 without an order from the physician. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life and hospitalization . Findings included: Record review of Resident #1's face sheet indicated he was [AGE] years old and was admitted on [DATE] with diagnoses including type 2 diabetes (an impairment in the way the body regulates and uses sugar (glucose) as a fuel), pneumonia, [CONDITION(S)] (damage or disease that affects the brain), dysphagia (difficulty swallowing) following nontraumatic intracerebral hemorrhage (most commonly results from hypertensive damage to blood vessel walls), COVID-19 (an infectious disease caused by the [CONDITION(S)]-CoV-2 virus), [CONDITION(S)] pharyngitis (infection of the throat and tonsils caused by the bacterium Streptococcus), and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Record review of Resident #1's medical record indicated there was no available MDS for review due to Resident #1's admission status. Record review of Resident #1's baseline care plan dated 1/14/22 indicated Resident #1 was a diabetic and his medications included insulin. Record review of Resident #1's medical record indicated there were no written orders for admission to include medications or the care of the resident. Review of Resident #1's hospital discharge packet faxed to the facility on [DATE] indicated there was no insulin or other diabetes medications included with the active medication list. Record review of nursing progress note dated 1/14/22 at 11:19 p.m., completed by LVN C, indicated Resident #1 arrived via ambulance and was nonverbal, alert, confused, had a [CONDITION(S)], had altered mental status, weakness, dementia, and metabolic encephalitis. Resident #1 had dark yellow urine, was incontinent to bowl and bladder and had Type 2 diabetes. Accuchecks AC and HS, Sliding scale [MEDICATION(S)] 10 units subQ every HS. He had multiple bruises on his knees and arms, he walked with assist, and was on room air. His family sent a lot of snacks in bags in his room. There was no documented physician notification of the admission or to confirm any medication orders. Review of Resident #1's hospital discharge packet faxed to the facility on [DATE] indicated there was no insulin or other diabetes medications included with the active medication list. The active medication list included: *Zolpidem 5 mg tablet 1 tab PO QHS (a sedative) *[MEDICATION(S)] 50 mg 1 tab PO daily (antipsychotic) * [MEDICATION(S)] 0.005% drops 1 drop ophthalmic (eye) QHS (used to treat [CONDITION(S)]) *Brinzolamide 1% drops, suspension 1 drop ophthalmic (eye) daily (used to treat [CONDITION(S)]) *Ramipril 5 mg capsule 1 cap PO daily (used to treat high blood pressure) *[MEDICATION(S)] HCl 30 mg tablet 1 tab PO TID (antidepressant) *Memantine 10 mg tablet 1 tab PO daily (used to treat Alzheimer's) *Gabapentin 800 mg tablet 1 tab PO TID (anticonvulsant) *[MEDICATION(S)] 10 mg tablet 1 tab PO daily (used to treat confusion (dementia) related to Alzheimer's disease) *Atorvastatin 10 mg tablet 1 tab PO daily (used to lower cholesterol) Record review of a hand-written telephone order dated 1/14/22 written by LVN C indicated Resident #1 was to have accuchecks AC and HS and was to receive [MEDICATION(S)] 10 units SQ every HS (used to control blood sugar). Record review of nursing progress note dated 1/16/22 at 1:10 a.m., completed by LVN C, indicated Resident #1's [MEDICATION(S)] insulin pen arrived, and she put it in the refrigerator. There was no documented evidence the resident was administered any [MEDICATION(S)]. Record review of Resident #1's blood sugar levels completed by LVN C in the electronic record indicated: *1/14/22 23:17 246 mg/dl, *1/15/22 20:26 422 mg/dl, *1/16/22 05:21 359 mg/dl, and *1/16/22 23:17 597 mg/dl. (normal blood sugar after not eating for at least 8 hours should be less than 100 mg/dl and less than 140 mg/dl 2 hours after eating) Record review of nursing progress noted dated 1/15/22 at 8:43 p.m., completed by LVN C, indicated LVN C administered Resident #1 the following medications at 8:30 p.m.: [MEDICATION(S)] HCL 30 mg 1 PO at bedtime, Baby Aspirin 81 mg 1 PO daily, [MEDICATION(S)] 10 mg 1 PO daily, [MEDICATION(S)] 50 mg tablet 1 tablet PO daily. LVN C documented all other medications were held and would resume tomorrow (1/16/22). Record review of Resident #1's January 2022 MAR/TAR indicated no medication administration or blood sugar checks on the 6:00 a.m. to 6:00 p.m. shift on 1/14/22, 1/15/22, or 1/16/22. Record review of nursing progress note dated 1/16/22 at 11:45 p.m., completed by LVN C, indicated Resident #1 was found next to his bed on his knees with his face and hands on the floor. Resident #1 was not responsive to his name or tapping on his shoulder. LVN C called for LVN A to assist Resident #1 to his bed. LVN C and LVN A picked him up off the floor. Resident #1 screamed ouch and had clear fluid coming from his mouth. He did not respond when asked if he was in pain. Resident #1's carotid artery was faint. Resident #1's BP was 157/75, HR was 84, respirations were 20, blood sugar was 597, and O2 was not obtainable. Started Resident on 02 3L via nasal cannula. LVN C called 911 and his daughter. Resident #1 had not received any medications on the night shift. Resident #1's (home) medications were in zip lock bag in the medication cart. The medications were brought to the facility by Resident #1's daughter and needed to be returned to her. Resident #1's [MEDICATION(S)] pen was in the refrigerator. There was no documentation of physician notification for the elevated blood sugar, fall, unresponsiveness, or discharge to the hospital. During an interview on 1/26/22 at 3:32 p.m., LVN C said Resident #1 was admitted [DATE]. LVN C said when she reviewed Resident #1's discharge papers from the hospital there were no medication orders. She said she saw discharge papers to check his blood sugar AC and HS and give [MEDICATION(S)] 10 units Sub Q HS. She said she did not have an order for sliding scale and his BS ran high. She said she wrote out a verbal order for [MEDICATION(S)] from the discharge paperwork. She said she did not call the physician for the order. She said she did not know why she did not call the physician and then said she did not know who the physician was. She was not aware of the facility's admission policy. She said she called the DON and the ADON and told them of Resident #1's high blood sugar and asked if the facility had a standard sliding scale. LVN C said the ADON told her not to worry because she was going to contact the NP. She said the ADON told her the facility did not have a standard sliding scale. She said a nurse on 01/15/22 (she could not recall who the nurse was) found Resident #1's orders and wrote the orders up for Resident #1's routine medications and assumed she faxed them over to the pharmacy. She said there was not a fax machine on the COVID unit where the resident was. She said she never received the routine medications for Resident #1 from the pharmacy. LVN C said she called Resident #1's family member about his behaviors and told her no medications had been delivered to the facility. She said Resident #1's family member took Resident #1's home medications to the facility on the evening of 1/15/22. She said Resident #1's family member said the Resident should receive the evening/night medications, so he would sleep. LVN C said she did not have orders in the computer to document the medications and did not document the medications on the MAR. She said she documented the medications she administered to Resident #1 in the nurse progress note. She said the only medication delivered to the facility was the [MEDICATION(S)] pen. She said the pen came in at 1:10 a.m. on 1/16/22 a.m. LVN C said she did not administer the medication because it was after the time parameter of HS. She said she did not call the physician to see if it was ok to go ahead and give the medication. She said Resident #1 was scheduled to have 10 units of the [MEDICATION(S)] on 1/16/22 HS but she could not find the [MEDICATION(S)] pen in the refrigerator. She said she came on shift at 6:00 p.m. on 1/16/22 and at approximately 6:15 p.m. she found Resident #1 on his knees with his head on the floor adjacent to his bed. LVN C said she called for the nurse who was leaving the COVIDCOVID unit to assist her and they helped him back to bed. LVN C said she assessed him, and he had no injuries. She called the ADON and reported Resident #1 would not respond to stimuli and was directed to send Resident #1 to the hospital for evaluation and treatment. She said she did not notify the MD of his change of condition. Record review Resident #1's hospital record dated 01/16/22 indicated Resident #1 presents to the emergency department via EMS intubated after being found unresponsive on the ground with unknown down time. Per EMS nursing home staff could not tell them anything about when the last time they saw him. He was found on the ground at an unknown time last known normal and GCS was 3. Patient was intubated in route. Blood sugar 547.The glucose level in the emergency room read high indicating the blood sugar was over 600 mg/dl. The critical care not from the emergency room note indicated Direct patient care, Resuscitation, additional history, Interpretation lab/[NAME] (laboratory and radiology), Documentation, Phone consult with MD, Unstable/abnormal vital signs, Life threatening conditions, Multiple evaluations. Resident #1's admitting diagnoses were acute [CONDITION(S)] (functional alteration of mental status due to systemic factors), acute kidney injury, [CONDITION(S)] (high blood sugar), and elevated CPK ([MEDICATION(S)] phosphokinase - elevated levels mean there has been injury or stress to muscle tissue, heart or brain). During an interview on 1/25/22 at 4:41 p.m., LVN A said she wrote Resident #1's medications on a telephone order sheet and handed it to the ADON on 1/15/22. She said she assumed the ADON faxed the medications to the pharmacy. She said there was not a fax machine on the COVID unit. She did not call the physician about the medications. During an interview on 1/25/22 at 12:21 p.m., the ADON said the admitting nurse was responsible for putting orders in the computer. She said a lot of times she would go back and check orders for new admissions. She said Resident #1 was admitted on a weekend, so she did not look at the admission. She said it was not her responsibility. She said she or the DON would usually look at admissions the following Monday. She said she did not receive any calls about Resident #1's medications. She said there was no system in place for admitting residents to ensure all staff were on the same page and knew what was needed for the resident prior to admission. She said she was at the facility for a little while on Saturday, 1/15/22, but could not remember if LVN A gave her Resident #1's medication list to fax to the pharmacy. During an interview on 1/25/22 at 12:57 p.m., the DON said the ADON was responsible for auditing the charts after an admission but had not been monitoring admissions. She said there was not anyone auditing the charts for residents admitted on a Friday evening or weekend. The DON said she noticed the batch orders (standing orders) were not in the computer so she put Resident #1's standing orders in from home on 1/15/22. She said she did not call the facility to ask why Resident #1's medications were not in the computer. She said the nurse who wrote the telephone orders for Resident #1 should have put the orders into the computer when they were written and sent them to the pharmacy. The DON said she received a call from the ADON on 1/16/22 saying Resident #1 was unresponsive and was being sent to the hospital. During an interview on 1/25/22 at 3:56 p.m., pharmacy technician S said Resident #1 was no longer active in their system. She said the only order they received from the facility was for the Resident #1's [MEDICATION(S)] insulin. She said the facility received the [MEDICATION(S)] on 1/15/22 at 11:57 p.m. During an interview on 1/25/22 at 1:46 p.m. Resident #1's family member said Resident #1 was discharged from the hospital to a different facility. She said his condition had declined since he was hospitalized . She said LVN C called her and asked for a list of Resident #1's medications but she did not have it. She said she did not know Resident #1 was on insulin. 2. Record review of Resident #2's face sheet indicated she was [AGE] years old and admitted on [DATE] with diagnoses including displaced bimalleolar fracture of left lower leg (two of the three parts or malleoli of the ankle are broken), encounter for surgical after care following surgery on the sense organs, [CONDITION(S)] with seizures or convulsions (mental condition in which a person has [CONDITION(S)], paralysis, or other nervous system (neurologic) symptoms), COVID-19 (an infectious disease caused by the [CONDITION(S)]-CoV-2 virus), anxiety disorder (excessive fear or anxiety), [CONDITION(S)] (deficiency of potassium in the bloodstream), and hypertension (high blood pressure). Record review of Resident #2's medical record indicated there was no available MDS for review due to Resident #2's admission status. Record review of Resident #2's baseline care plan dated 1/14/22 indicated neither pain or pain medication was addressed. Record review of Resident #2's medical record indicated no admission orders for medications or immediate care of Resident #2. Record review of Resident #2's cumulative orders dated 2/1/22 indicated all medications were put into the computer (obtained from the active orders from the hospital) on 1/14/22 and were pending confirmation. The medications included Tylenol 650 mg as needed for fever. [MEDICATION(S)] 0.1 mg every 12 hours as needed for high blood pressure, [MEDICATION(S)] Sodium 100 mg three times a day for constipation, [MEDICATION(S)] Powder every 24 hours as needed for constipation, [MEDICATION(S)]-Acetaminophen 5-325 mg every four hours for moderate to severe pain, [MEDICATION(S)] 600 mg every 8 hours as needed for mild pain, and [MEDICATION(S)] 50 mg at bedtime for depression. Record review of nursing progress note dated 1/14/22 at 10:29 p.m., completed by LVN C, indicated 1900: Patient (Resident #2) has medications that needs clarification with the DR. There was no documentation the physician was notified to verify orders. Record review of nursing progress note dated 1/15/22 at 2:05 a.m., completed by LVN C, indicated 2000 pm-Patient (Resident #2) requested a pain pill due to her left ankle ORIF, pain level 9. Acetaminophen/COD #4 (home medication), order reads 1 tablet by mouth every four hours as needed for pain. There were no orders for the administration of Acetaminophen with [MEDICATION(S)] #4. Record review of nursing progress note dated 1/15/22 at 2:13 a.m., completed by LVN C indicated 0000 (midnight) am-Patient (Resident #2) requested pain pill for left ankle ORIF, level 8. She brought her own medication. Notified the ADON to verify it's o.k. to administer her own medication and she said it was o.k. There were no physician orders for Resident #2's medication brought from home. Record review of nursing note dated 1/15/22 at 5:33 a.m., completed by LVN C, indicated 0400 a.m.-Administered patient (Resident #2) a pain pill (from home). Pain level at 8. There were no orders for the administration of pain medication. Record review of nursing note dated 1/15/22 at 9:45 a.m., completed by LVN A indicated Resident #2 discharged home with her personal medications. During an interview on 1/25/22 at 3:56 p.m., pharmacy technician S said they had no record of Resident #2 in their system. She said when a resident was admitted , the facility would fax the orders to the pharmacy, so the medications could be filled. During an interview on 1/26/22 at 11:33 a.m., LVN C said she did not notify MD E of Resident #2's admission. She said she did not verify or obtain physician orders for Resident #2's medications. She said Resident #2 brought her personal medications to the facility. She said she called the ADON and was told it was o.k. to administer Resident #2's Acetaminophen/COD #4. She said she did not have physician orders to administer Resident #2's Acetaminophen/COD #4. During an interview on 1/26/22 at 10:59 a.m., the ADON said she could not recall any phone calls from LVN C about pain medications for Resident #2. The ADON said she told the administrator when residents were admitted on Friday evenings or on the weekend and needed narcotics would not be able to get pain meds until the physician saw the resident. She could not recall when she told the administrator the information. During an interview on 1/25/22 at 3:47 p.m., the DON said she did not receive any calls from LVN C regarding physician notification or medication clarification for Resident #1 or Resident #2. During an interview on 1/25/22 at 4:04 p.m. MD E said he was not notified of any admissions on 1/14/22 involving Resident #1 or #2. He said he was never notified of Resident #1 being admitted or that he had elevated blood sugars. He was not aware Resident #1 had been sent to the hospital for a blood sugar of 597. MD E said that was a high blood sugar. MD E said it was easy to give an order for a sliding scale for insulin. MD E said he was disappointed and the whole situation should not have happened. He said he or someone on-call was always available to the facility for the admissions. During an interview on 1/26/22 at 11:01 a.m., MD E said he was notified about pending admissions but did not always get notified when the resident was physically admitted . He said diabetics usually had orders for sliding scale insulin. If the blood sugar was still not in control, then the attending physician must be notified for further orders. He said the facility had to notify him before noon on Fridays for him to order any narcotics. He did not receive any calls about Resident #2's pain or pain medication. Record review of the facility's undated Medication Administration policy indicated: Medications shall be administered in a safe and timely manner, and as prescribed .3. Medications must be administered in accordance with the orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents reviewed for accidents and hazards. (Resident #1) The facility did not provide a fall mat, or ensure the bed was placed next to a wall, as required on Resident #1's care plan. On 0/10/18, Resident #1, noted to be at risk for falls, fell out of bed and sustained a broken left hip. This failure could place the census of 42 residents at risk for neglect and not receiving nursing services as required. Findings included: Physician orders [REDACTED].#1, admitted [DATE], and was [AGE] years old with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 had severe cognitive impairment, was totally dependent with extensive 1 to 2 person physical assistance for activities of daily living (ADLs), and utilized a wheelchair for mobility. A Care Plan revised on 12/21/17 indicated Resident #1 had a potential for injury due to falling, related to her cognitive deficits and impulsiveness. The care plan indicated she required total assistance with all transfers. Interventions listed to place Resident #1's articles within her reach, to remind/encourage the resident to use her call light, to keep her bed in a low position, to place fall mats on the floor at her bedside, and to place her bed next to a wall to minimize the risk of falling. A nursing note dated 01/10/18 at 4:45 p.m. and completed by LVN A indicated she heard Resident #1 screaming and went to the resident's room. The note indicated LVN A found Resident #1 on the floor beside the her bed. LVN A documented she assessed Resident #1 and there was swelling to the resident's left hip, and Resident #1 was complaining of pain to her left hip and knee. LVN A called the physician and received an order to send Resident #1 to the emergency room for evaluation and treatment. The note indicated RN A asked Resident #1 what happened and the resident told her she was getting the silverware off of the floor for my boss and fell on the floor. There was no documentation related to the missing fall mat, whether or not the bed was in the low position, or next to the wall. An Incident Report dated 01/10/18, regarding Resident #1's fall out of bed, did not mention fall mats, the position of the bed, or if it was next to the wall. A Fall Assessment for Resident #1 dated 1/10/18 indicated she was at high risk for falls. An Investigation Follow up dated 1/11/18 regarding interventions implemented in the past for Resident #1 included to maintain her bed in the lowest position and her call light within reach. The recommendations and new interventions included Resident #1 should have fall mats at her bedside. During an observation and interview on 1/24/18 at 3:50 p.m., Resident #1 was lying in bed. The call light was on the floor and not in reach. There were no mats on the floor for either side of the bed, and the bed was not against the wall. The over-bed rolling table was pushed against the wall and not in reach. There was a large plastic mug on the night stand that was between the bed and the wall and not in reach. Resident #1 said she could not recall what she was doing when she fell out of bed. She said she hurt herself and touched her left hip area. She could not recall if there was a mat on the floor. During observation and interview on 01/24/18 at 4:00 p.m., the DON acknowledged Resident #1's call light was on the floor as she placed the call light within Resident 1's reach. The DON said she did not know why the fall mats were not on the floor. She said Resident #1 had returned to the facility 1 hour earlier from a follow up appointment regarding her [MEDICAL CONDITION]. During an interview on 01/25/18 at 11:43 a.m., CNA A said residents with a risk of falling had fall mats on the floor. She said she could not recall if Resident #1 had fall mats. She said if a resident had fall mats, the aides would find the information on the resident's care sheet. During an interview on 01/25/18 at 11:45 a.m., CNA B said she could not recall Resident #1 having any fall mats on the floor. During an interview on 01/25/18 at 12:30 p.m., the DON said the floor mats, bed position, and bed location next to wall were not added to Resident #1's care sheet. During an interview on 01/25/18 at 12:50 p.m., LVN B said she was not aware Resident #1 was supposed to have fall mats. She said she did review residents' care plans but she could not recall if Resident #1 had fall mats. During an interview on 01/25/18 at 1:19 p.m., LVN A said Resident #1 had 1 fall mat on the left side of her bed, but not on the right side, and Resident #1 had fallen off the right side of the bed. She said there usually were 2 mats on the floor. She said she did not know why there was only 1 mat beside Resident #1's bed when she fell out of bed. During an interview on 01/25/18 at 1:27 p.m., CNA C said there were no fall mats in place for Resident #1. He said he was not aware there was supposed to be any fall mats on the floor for Resident #1. The CMS Form 672 dated 01/24/18 indicated a census of 42 residents.