Every finding on record at Henrico Health & Rehabilitation Center

Based on observation, interview and clinical record review the facilty staff failed to maintain an effective pest control program for two of two units in the facility. For two of two units in the facilty, the failed to ensure resident areas were free from pests and rodents. On 7/6/26 during an interview with R88 2 flies were noted to be buzzing around R8 and she was observed waving them away. During the three days of survey flies were observed in patient rooms and hallways in both North and South Units. A review of the pest control service tickets dated 5/7/26, 5/28/26, 6/15/26 and 7/2/26 revealed the following regarding pest activity: Location-South Wing exterior doorObservation - Door GapRecommendation - Seal GapResponsibility - CustomerPending Customer Resolution. On the afternoon of 7/7/26 an interview was held with maintenance director who was asked about the flies, and he stated that the flies come in when the door is open. As of 7/6/26 the gap had not been sealed as recommended by the pest control company. On 7/8/26 the following information was gathered during the Resident Group Meeting was held on 7/8/26 at 12:48 pm the following are excerpts of notes taken during the meeting: Cockroaches/Ants, residents report seeing large cockroaches in rooms. Three out of six residents report seeing cockroaches within the last week. R88 reported her roommate had a pest control box in her room and that a staff member had come in to remove it because it was full. A review of the pest control log books revealed siting of cockroaches and spiders in patient rooms and patient care areas. A review of the pest control invoices revealed the following: 5/28/26 -Location station 1 75-100% bait eaten pest type rodent6/15/26 kitchen area as well as office as well as fitness area activity noted6/25/26 -Location station 1 75-100% bait eaten pest type rodent7/2/26 South Wing station #3 common area observation - activity dead German roaches count 8. The facility is having the exterminator come out approximately every 2 weeks however the pest control program is ineffective as the pest issue is ongoing. On 7/8/26 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on observation, interview, cliinical record review and facility documentation the facility staff failed to ensure a clean, comfortable homelike environment for four residents (R88, R6, R94, R55) and the facility in a survey sample of 43 residents. 1. The facility staff failed to ensure appropriate number of linens available, laundry completed in a timely manner, adequate pest control, and repairs made in a timely manner. On 7/6/26 during an interview with R88 2 flies were noted to be buzzing around R88 and she was observed waving them away. During the three days of survey flies were observed in patient rooms and hallways in both North and South Units. A review of the pest control service tickets dated 5/7/26, 5/28/26 and 6/15/26 revealed the following regarding pest activity: Location-South Wing exterior door Observation – Door Gap Recommendation - Seal Gap Responsibility – Customer Pending Customer Resolution. On the afternoon of 7/7/26 an interview was held with maintenance director who was asked about the flies, and he stated that the flies come in when the door is open. On 7/6/26 at 12:45 p.m. an interview was conducted with R88, who complained that her toilet had not been working since Friday and didn't get fixed until this morning. R88 stated that she used the broken toilet because she could not make to the toilet at the nurses station in her wheelchair every time she has to go. R88 stated that she informed the staff and stated that the CNA (Certified Nursing Assistant) and the Nurse both knew about it. She stated that she was upset that she had to put up with the stench all weekend and she stated, I ate my meals all weekend with that odor in my room. On 7/7/26 at 1:00 p.m. an interview was conducted with CNA4 who stated that she knew R88's toilet would not flush since Friday (7/3/26). CNA4 stated that she had told the nurse. CNA4 stated that when she came in on 7/6/26 and saw that the toilet was still not fixed she made sure maintenance was called to her room. On 7/7/26 at approximately 2:45 pm an interview was conducted with the Maintenance Director who stated that he was not aware of the toilet being broken until the morning of 7/6/26. When asked how emergent maintenance reports are generated, he stated that they used to use a computerized system, however now the staff call him directly. The Maintenance Director stated that he did not consider the toilet an emergency because there were other bathrooms R88 could use. On 7/7/26 at approximately 3:25 pm an interview was conducted with LPN7 who stated that she knew the toilet was broken but it was not an emergency because she can use the bathroom at the nurses station. On 7/8/26 during the end of day meeting the Administrator was asked for a policy on maintenance repairs and none was provided. During the three days of survey, one of the rest rooms in the lobby intended for visitors as well as staff and residents was out of service all three days. R88 stated that the facility has not got enough towels and washcloths and sheets. R88 stated that linen shortage has been a problem and that the laundry doesn't get done timely, she added you can check resident council minutes we have brought it up. A review of the resident council minutes revealed that during the months of March and April residents complained of clothing not being picked up on their laundry day. The facility answered as follows on 4/13/26: We create [sic] a new laundry schedule to make sure all residents' laundry is picked up promptly. There may be times that it's not picked up on its scheduled due to the fact that your laundry attendant may be off. On 5/27/26 the resident council minutes reflect Residents request maintenance fixes the dining room ice machine, Residents state there is a shortage of linen and washcloths on the floors. On 6/1726 the minutes reflect Residents state clothing and personal laundry is not being completed in a timely or consistent manner, and the shortage of towels, washcloths and linens continues. On 6/24/26 the answer signed by the Administrator stated the following: Due to changing companies is the reason for linen shortage. Staffing issues was the problem for residents clothing issues . During the course of the survey a Resident Group Meeting was held on 7/8/26 at 12:48 pm the following are excerpts of notes taken during the meeting: R88-Resident Council President reported no water in her bathroom from Friday, 7/3 until Monday 7/6/2026. She reports having to get water from the sink in her room and put in the toilet in order to flush. She did not know what caused the issue and reported to staff. Cockroaches/Ants, residents report seeing large cockroaches in rooms. Three out of six residents report seeing cockroaches within the last week. R88 reported her roommate had a pest control box in her room and that a staff member had come in to remove it because it was full. On 7/8/26 the Administrator was made aware of the concerns, and no further information was provided. 2. The facility staff failed to ensure one of two shower rooms was cleaned and disinfected before and after each resident use to prevent potential contamination. Resident (R55) was admitted to the facility on [DATE] post recent hospitalization after several falls at his residence. He sustained full thickness burns to bilateral extremities from a brush fire at his home in April 2026 that required auto graft (a permanent skin transparent from a healthy skin) and RECELL Autologous Cell Harvesting Device, an advanced regenerative treatment where his own healthy skin was processed into a liquid spray and sprayed onto the burn wounds. Other diagnoses included but not limited to hypertension, alcohol and cocaine use disorder, left hip replacement, chronic venous insufficiency, amputation left above the knee on 5/8/26 with placement of BTM (a reconstructive technique applied to the surgical site to help the body regrow a new layer of skin and tissue). The admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 6/12/26 coded R55 in Section C. 0100 Cognitive Pattern as a 15/15 with Brief Interview for Mental Status (BIMS) indicating R55 was cognitively intact. Section GG Functional Ability for shower/bath as partial/moderate assistance. On 7/6/26 at 11:55 AM, R55 reported, something needs to be done about that filthy shower room because it has poop on the walls, I take a shower every day and I think I might have gotten MRSA [Methicillin Resistant Staphylococcus Aureus, an infection caused by a type of staph bacteria that becomes resistant to many of the antibiotics used to treat ordinary staph infections, Mayo Clinic] from the filth. R55 also stated that the nurses change his dressing daily in addition to follow-up appointments to the burn clinics, and that he showers daily and goes on leave of absence to visit a female friend as often as he can get a ride and that she was a nurse and would sometimes wrap or re-wrap his wound. At 1:35PM, an inspection of the shower room Unit 2 was completed and revealed several areas of brown residue/smears on outside and inside of the shower stall, bath chair with white powdery residue on seat, and baseboards with brown/black substance on tiles and chalking, shower stall curtain noted wet with black substance across the bottom and a wet hospital gown on the floor in front of the commode, bits of trash on the floor. On 7/8/26 at 10:50 AM, an interview was conducted with the Infection Preventionist sharing with her R55's concern that he was afraid he may have gotten MRSA from the filthy shower. The Infection Preventionist accompanied the surveyor to the shower room for a second inspection. Again, the findings included several areas of brown residue/smears on outside and inside of the shower stall, bath chair with white powdery residue on seat, and baseboards and wall tiles with brown/black substance on tiles and chalking, shower stall curtain noted wet with black substance across the bottom. The hospital gown had been removed, and floors were free of the trash on the floor. An interview was conducted with LPN #6 and RN #1 on who cleans the shower room and shower stalls after a resident's use. According to LPN#6 and RN#1 they stated the C.N.A is supposed to clean after the resident and then housekeeping cleans the shower room every day. They stated they had seen the new housekeeping girl in the shower room this morning. An interview with Housekeeping Aide Other #5 he confirmed it was the responsibility of the housekeeping staff to clean the shower room every day and that the new girl cleaned it today. An interview was conducted with Housekeeping Aide Other #4, and she stated she had cleaned the shower room earlier this morning. The Housekeeping Aide accompanied the surveyor to the shower room at which time the findings of the brown residue/smears on outside and inside of the shower stall, bath chair with white powdery residue on seat, and baseboards and wall tiles with brown/black substance on the tiles and chalking, shower stall curtain noted wet with black substance across the bottom were pointed out. The Housekeeping Aide Other #4 stated, Oh. This curtain wasn't wet this morning. I didn't see those brown smears on the wall. The Infection Preventionist stated she would notify the Director of Environmental Services and have the shower room re-cleaned. On 7/7/26 during the end of the day meeting with the Administrator, Director of Nursing and Regional Director of Operations were notified of the findings. A request for the facility's policy and procedure on cleaning the shower room. The Administrator provided a copy of a policy titled 7-Step Daily Washroom Cleaning, Healthcare Services Group, Inc, which read in part empty trash, dust mop floor, clean and sanitize sink and tub (use Germicide to clean the sink to be sure it is disinfected) clean and sanitize the commode, spot clean walls and/or partitions, damp mop floor. According to the Administrator the facility does not have a policy specific to the cleaning of the shower room. No further information was provided. 3. For Resident # 6, the facility staff failed to ensure a clean, comfortable homelike environment During the initial tour of the facility on 07/06/2026, at 12:30 p.m., it was observed that the air conditioning unit was in disrepair. The outside cover was not attached on the right side of the unit. There were baseboards missing along the walls of the room. The second door to the dressers on the wall was missing the door and the two drawers on the bottom of the closet were pulled open. Clothes were observed in disarray in the drawer and closet. In the top drawer, there were clothes in a clear plastic bag that was open, over flowing and partially hanging out of the closet. The overbed table for the resident residing in the first bed (Resident # 6) was in disrepair. The molding along the side of the overbed table was not attached and dangling. Resident # 6 was not in the room on the initial tour. The roommate (Resident # 92) was lying in the bed by the window but did not answer questions about the issues noted in the room. On 07/07/2026 at 9:40 a.m., tour of Resident # 6's room revealed that the above issues remained the same as observed upon initial tour. On 07/08/2026 at 10:00 a.m., tour of Resident # 6's room revealed the cover to the HVAC unit was attached to the unit on both sides. The molding on Resident # 6's overbed table was still unattached and dangling. The baseboard molding was still in disrepair. The closet door was still missing and clothes were still in the plastic bag in the drawer. An interview was conducted on 07/08/2026 at 11:00 a.m. with Resident # 6 who stated that there were issues with things not being fixed in the room. Resident # 6 stated that the overbed table had been broken for a long time. Resident # 6 stated the staff members were aware of the issues in the room involving the overbed table, missing baseboards and unattached cover to the air conditioning unit. On 07/08/2026 at 11:10 a.m., an interview was conducted with the Unit Manager who stated the facility staff was aware of the issues in the room involving the closet door and baseboard molding. The Unit Manager toured the room with the surveyor, observed the findings and stated the information had been reported to the administrative team. The Unit Manager stated the issues should be reported to Maintenance and repaired. On 07/08/2026 at 1:05 p.m., an interview was conducted with the facility Administrator who stated the facility was in the process of replacing baseboards in some of the rooms. The Administrator stated that the facility was under new ownership since 07/01/2026 and any issues with the environment were being addressed. The Administrator toured the room with the surveyor and stated the facility would address the issues observed. The Administrator stated it was important for the residents to have a clean, comfortable, homelike environment. She stated the staff should notify the Maintenance department of any issues that need to be repaired. On 07/08/2026 at 1:12 p.m., an interview was conducted with the Maintenance Director who stated he was not aware of the closet door being in need of repair. The Maintenance Director toured the unit with the surveyor and observed the findings. He stated he had not been informed by the facility staff of the issues but would repair the problems immediately. Staff members were observed entering the room, delivering trays and providing care during the survey. There were no observations of staff members trying to repair the closet door. During the end of day debriefing on 07/08/2026, the facility administrator, Director of Nursing and Regional [NAME] President of Operations were informed of the findings. No further information was provided. 4. For Resident # 94, the facility staff failed to ensure the closet was properly functioning. On 07/06/2026 at 12:45 p.m. during the initial tour, in Resident #94's room observations noted the dresser across from the bed had a broken second cabinet door (right side). The second door had hinges that were not connected at the top. The door was hanging with the only attachment at the bottom of the door. On 07/07/2026 at 10:20 a.m., the closet door was observed still hanging by the bottom attachment. Resident # 94 was not in the room. The roommate was sitting up in the bed by the window. The roommate (Resident # 27) stated the door had been that way for a while. Staff members were observed entering the room, delivering trays and providing care during the survey. There were no observations of staff members trying to repair the closet door. On 07/08/2026 at 11:15 a.m., an interview was conducted with the Unit Manager who stated the facility staff was aware of the broken closet door. The Unit Manager stated the information had been reported to the administrative team. On 07/08/2026 at 1:05 p.m., an interview was conducted with the facility Administrator who stated the facility staff should notify the Maintenance department of any issues regarding the environment in the residents' rooms. The Administrator stated that the facility was under new ownership since 07/01/2026 and would continue to address any issues in the environment in the resident's rooms. The Administrator stated it was important for the residents to have a clean, comfortable, homelike environment. She stated the staff should notify the Maintenance department of any issues that need to be repaired. On 07/08/2026 at 1:12 p.m., an interview was conducted with the Maintenance Director who stated he was not aware of the closet door being in need of repair. The Maintenance Director toured the unit with the surveyor and observed the findings. He stated he had not been informed by the facility staff of the issue but would repair it immediately. During the end of day debriefing on 07/08/2026, the facility administrator, Director of Nursing and Regional [NAME] President of Operations were informed of the findings. No further information was provided.

Based on clinical record review, facility staff interview, and facility document review the facility failed to ensure a complete and accurately documented clinical record for one of 43 residents in the sample, Resident #106 (R106).The findings include:For Resident #106 (R106) the facility failed to maintain an accurately documented clinical record regarding the resident receiving the medication Gabapentin, a medication used to treat nerve pain.Diagnoses for R106 include displaced trimalleolar fracture, hemiplegia and hemiparesis following cerebral vascular accident, diabetes mellitus, asthma, depression, hypertension, morbid obesity, hyperlipidemia, cognitive communication deficit, and anxiety. On R106's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 5/19/2026, R106 scored a 15 out of 15 on the brief interview for mental status (BIMS) indicating that R106 was cognitively intact. Review of R106's clinical records demonstrated a physician's order for Gabapentin 800 milligrams (mg) four times daily dated 5/9/2026 with a stop date of 6/9/2026. A physician's progress note was available in the clinical record dated 6/8/2026 at 5:06 PM. The physician's reason for the visit was needs refill on gabapentin. The physician stated that R106 wanted to continue with gabapentin as it helps with neuropathic pain. The physician then stated to continue with present meds. There was no corresponding physician's order noted in the clinical record for gabapentin on 6/8/2026.Review of R106's medication administration record (MAR) revealed that R106 did not receive Gabapentin on 6/9/2026, 6/10/2026, and 6/11/2026 at all. On 6/12/2026, R106 received only one dose of Gabapentin at 9:00 PM. A physician's order for Gabapentin 800mg four times a day dated 6/12/2026 was noted in the clinical record. This was a verbal order from the physician that was placed into the clinical record by Licensed Practical Nurse (LPN) #6.An interview was conducted with LPN #5 on 6/8/2026 at 12:13 PM. LPN #5 stated that when a medication has a stop date placed into the clinical record by the provider, the provider must re-order the medication and nursing is not involved.During an interview with LPN #6 that was conducted on 6/8/2026 at 12:30 PM, LPN #6 stated that R106 asked her about not receiving her Gabapentin on 6/12/2026 which prompted the LPN to notify the physician. The physician told LPN #6 that R106 should be receiving that medication and gave her a verbal order for Gabapentin. LPN #6 stated that because Gabapentin is a controlled substance, the physician has to fax a prescription for Gabapentin to the pharmacy and that staff has to frequently remind this physician to fax prescriptions to the pharmacy. LPN #6 stated that if nobody reviews the physician's progress notes, the omission could be missed.An interview was conducted with the Director of Nursing (DON) on 6/8/2026 at 1:05 PM. The DON stated that the physician has access to put orders directly into the electronic medical record, but narcotic/controlled substances require an actual prescription to be sent to the pharmacy. The DON stated that when a night supervisor is available, the night supervisor will review the resident's charts for errors. If no night supervisor is available, review of resident's clinical records for errors occurs at clinical meetings that occur daily Monday through Friday. The DON did not recall discussing R106 in these meetings. The DON noted that this particular physician had a pattern of forgetting to send the prescriptions to the pharmacy.Review of the facility policy titled Controlled Substance Prescriptions dated September 2018 with a most recent revision date of August 2020 demonstrated that the prescriber issuing the chart order must also provide the pharmacy with a valid prescription to ensure delivery of medication.The above information was presented to facility leadership on 6/8/2026 at 5:45 PM. No further information was provided prior to exit.

Based on resident interview, staff interview, clinical record review, and facility document review the facility failed to provide routine medications for two of 43 residents in the sample, resident #106 (R106) and resident #54 (R54)The findings include: 1. For Resident #106 (R106) the facility failed to administer follow facility policy regarding an unavailable medication resulting in a missed administration of a routine medication, doxazosin mesylate, a medication for high blood pressure with an off-label use for depression. Diagnoses for R106 include displaced trimalleolar fracture, hemiplegia and hemiparesis following cerebral vascular accident, diabetes mellitus, asthma, depression, hypertension, morbid obesity, hyperlipidemia, cognitive communication deficit, and anxiety. On R106's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of [DATE], R106 scored a 15 out of 15 on the brief interview for mental status (BIMS) indicating that R106 was cognitively intact. Review of R106's clinical records revealed a physician's order for doxazosin mesylate two milligrams (mg) daily for depression dated [DATE] with a start date of [DATE]. This order was noted to have a stop date of [DATE]. R106's medication administration record (MAR) failed to demonstrate administration of doxazosin mesylate two mg on [DATE]. A nurse's note was available in the clinical record dated [DATE] at 10:33 PM, an administration note for doxazosin mesylate two mg, stating new admission, unavailable in Omnicell. Order updated to start [DATE]. A corresponding physician's order was noted in the clinical record dated [DATE] for doxyzosin mesylate two mg with a start date of [DATE]. The nurse who wrote this progress note was not available for interview. Review of the facility policy titled Unavailable Medications dated [DATE] with a most recent revision date of [DATE] demonstrated that when a medication is unavailable for administration, nursing staff will notify the attending physician (or on-call physician when applicable) of the situation and explain the circumstances, expected availability, and alternative therapy(ies) available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or direction. The policy then states that nursing should obtain a new order and cancel/discontinue the order for the non-available medication. There was no indication in the clinical record that nursing staff notified the attending or on-call physician regarding the unavailability of doxazosin mesylate two mg on [DATE]. This information was presented to facility leadership on [DATE] at 5:45 PM. No further information was provided prior to exit. 2. For Resident #54 the facility staff failed to ensure the medications eszopiclone 2 mg and gabapentin 100mg were available for administration. Resident #54's clinical record listed diagnoses which included but not limited to unilateral primary osteoarthritis, right knee, unspecified rotator cuff tear or rupture of right shoulder, and rhabdomyolysis. Resident #54's most recent quarterly minimum data set with an assessment reference date of [DATE] assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #54's comprehensive care plan was reviewed and contained plans for the resident has a risk for pain related to rhabdomyolysis, Unspecified rotator cuff tear or rupture of right shoulder, not specified and unspecified rotator cuff tear or rupture of left shoulder, not specified and psychoactive medications: the resident is at risk for complications related to psychoactive medication use secondary to diagnoses of: depression; sleep. Interventions for these plans included administer medications as ordered. Resident #54's clinical record contained a physician's order summary which read in part, Eszopiclone Oral Tablet 20 mg (Eszopiclone). Give 1 tablet by mouth at bedtime for sleep and Gabapentin Capsule 100 mg. Give 100 mg by mouth at bedtime for pain. Resident #54's electronic medication administration records (eMAR) for the months of June and [DATE] were reviewed and contained entries as above. The entry for eszopiclone 2 mg was coded 9 on [DATE] and [DATE], was blank on [DATE], and was coded 5 on [DATE]. The entry for gabapentin 100 mg was coded 5 on [DATE]. Chart code 5 is equivalent to Hold/See Progress Notes and chart code 9 is equivalent to Other/See Progress Notes. Resident #54's progress notes were reviewed and contained notes which read in part, [DATE] 21:53:00 Eszopiclone Oral Tablet 2 mg. Give 1 tablet by mouth at bedtime for sleep. no medication available, [DATE] 21:53 Eszopiclone Oral Tablet 2 mg. Give 1 tablet by mouth at bedtime for sleep. prescription ordered and will be here on the next delivery, [DATE] 23:03 Eszopiclone Oral Tablet 2 mg. Give 1 tablet by mouth at bedtime for sleep. medication not available or in omni cell, awaiting pharmacy to deliver, md notified new order, hold meds give when medication arrives rp (responsible party) made aware, and Gabapentin Capsule 100 mg. Give 100 mg by mouth at bedtime for pain. medication not available md made aware hold med give when medication to arrive rp notified. Surveyor reviewed medications available in the facility emergency medication supply and Gabapentin 100 mg capsule was listed as available. Surveyor requested and was provided with a facility policy entitled Medication Unavailability which read in part, A licensed nurse discovering a medication on order that is unavailable will initiate appropriate steps to ensure medical treatment is provided as ordered. The concern of not ensuring Resident #54's medications were available for administration was discussed with the administrator, director of nursing, chief clinical officer, and regional director of operations on [DATE] at 4:00 pm. Surveyor informed the administrator and director of nursing that the gabapentin was available in the emergency medication supply. On [DATE] at 5:30 pm, the director of nursing stated to surveyor that the reason the gabapentin was not taken from the emergency medication supply was because the resident did not have a current prescription on file with the pharmacy. Surveyor spoke with the QA (quality assurance) pharmacist for the contract pharmacy on [DATE] at 8:40 am. QA pharmacist stated that the resident did have a current physician's order for gabapentin but did not have current prescription on file on [DATE]. QA pharmacist stated a prescription for a 90-day supply was received on [DATE] and expired on [DATE]. QA pharmacist stated the pharmacy had received a new prescription for the gabapentin on [DATE].

Based on resident/staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain all mechanical hot water heater in safe operating condition.The findings include: The facility staff failed to ensure hot water was available in the facility from 1/11/26 to 1/13/26.On 1/13/25 at 12:45 PM observation of the kitchen dish washing station was completed. Temperature observed initially on the dish washer on entry was 155 degrees. OSM (other staff member) #3, the dietary manager was present and restarted the load. Unable to reach 165 degrees despite multiple restarts and draining the dish machine. OSM #3 brought OSM #8 the maintenance tech into the dish wash area. OSM #8 stated the reason for the delay in reaching required temperature was due to the lack of hot water which fed the dish machine. OSM #8 stated, it is doubtful that the 165 degrees can be reached. Asked why there was a lack of hot water in the facility and when this began, OSM #8 stated, it started 1/11/26 during the night to early morning. The reason is that our gas supplier-AmeriGas, did not refill the tanks which feeds our water heater and then flows to the dish machine. When asked when this was to be corrected, OSM #8 stated, they are bringing a delivery today. After approximately 30 minutes of running the dish machine wash temperature reached 167 degrees and rinse temperature reached 183 degrees. Approximately 1:25 PM, OSM #3, the dietary manager was asked what would occur for the supper meal, OSM #3 stated, we will use disposable dishes until we can get hot water. On 1/14/26 at 10:15 AM, an interview was conducted with OSM #2, the maintenance director. Asked about the hot water and his response, OSM #2 stated, yes, I came in on Sunday 1/11/26 and checked the boiler room first. Everything was okay there but the gas feeding the water heater was low. We have a piece of equipment that notifies our company [gas supplier], AmeriGas, when it reaches 30% so they can come and refill it. I do not know why that did not happen. Asked if he called the gas company on Sunday for them to fill up the tanks, OSM #2 stated there is no emergency number and no way to contact them till Monday 1/12/26. I called them on Monday, there was an outstanding bill issue, and they had not received the electronic alarm notification that it was below 30%. We had a check cut, and they could not come out till yesterday 1/13/26. They are ordering the part for the electronic alarm notification and will put it on the tanks when it comes in. The lack of hot water was in resident areas, kitchen, laundry and public restrooms. On 1/14/26 at 3:30 PM ASM (administrator staff member) #1, the administrator, RN (registered nurse) #1, the director of nursing and ASM #3, the clinical compliance specialist/acting regional was informed of the above concerns.No policy was provided.No further information was provided prior to exit.

Based on resident/staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a safe, functional and comfortable environment in the facility.The findings include: The facility staff failed to ensure hot water in the facility from 1/11/26 to 1/13/26.On 1/13/26 during initial resident observations, multiple residents stated that there was no hot water in the facility. When hot water tap was turned on in resident rooms and public bathrooms, there was no hot water.On 1/13/26 at 11:05 AM, an interview was conducted with CNA (certified nursing assistant) #1. Asked when the facility lost hot water, CNA #1 stated, it was out last night and today. I heard it started earlier, but this is my first day back so I am not sure.On 1/14/26 at 10:15 AM, an interview was conducted with OSM #2, the maintenance director. Asked about the hot water and his response, OSM #2 stated, yes, I came in on Sunday 1/11/26 and checked the boiler room first. Everything was okay there but the gas feeding the water heater was low. We have a piece of equipment that notifies our company, AmeriGas, when it reaches 30% so they can come and refill it. I do not know why that did not happen. Asked if he called the gas company on Sunday for them to fill up the tanks, OSM #2 stated there is no emergency number and no way to contact them till Monday 1/12/26. I called them on Monday, there was an outstanding bill issue, and they had not received the electronic alarm notification that it was below 30%. We had a check cut, and they could not come out till yesterday 1/13/26. They are ordering the part for the electronic alarm notification and will put it on the tanks when it comes in. The lack of hot water was in resident areas, kitchen, laundry and public restrooms. On 1/14/26 at 3:30 PM ASM (administrator staff member) #1, the administrator, RN (registered nurse) #1, the director of nursing and ASM #3, the clinical compliance specialist/acting regional was informed of the above concerns.No policy was provided.No further information was provided prior to exit.

Based on observation, resident / staff interview, facility document review, and clinical record review, it was determined the facility staff failed to follow the menu as provided for one of 38 residents, R55. The findings include: The facility staff failed to follow the menu for R55. R55 was admitted to the facility on [DATE] with diagnosis that included but were not limited to COPD (chronic obstructive pulmonary disease), diabetes mellitus and CHF (congestive heart failure).The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 12/13/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers/bathing/dressing and set-up for eating. Section L-oral/dental status-codes the resident as 'no missing teeth and edentulous-no'. A review of the comprehensive care plan dated 12/19/23 revealed, FOCUS: Resident is at risk for weight fluctuations, loss or malnutrition related to Respiratory Failure, CHF, Severe Morbid Obesity due to Excess Calories, high BMI, Lymphedema Refuses to be weighed. Requests large portion. INTERVENTIONS: Honor resident meal preference. An interview was conducted on 1/13/26 at approximately 11:20 AM. R55 stated, watch what we have for lunch. The menus are not followed and they do not cook a lot of the food, just sandwiches and hot dogs and they just throw the food on the plate. A review of the Resident Council Minutes revealed: 7/2/25 Food is not good and is coming to rooms cold, getting the same thing, menu not posted for supper. 9/24/25 Food is served cold, Residents have commented that their meals seem overly simplistic or 'kid friendly'. 10/23/25 Food cold, do not have proper utensils. 12/11/25 Food consistently cold. Menu posted and served to residents for 1/13/26 on the unit: lunch: tuna salad sandwich, chips, diced beets, fruit; supper: chicken salad sandwich, chips, fruit, ice cream. Menu posted and served to residents for 1/14/26 on the unit: lunch: hot dog, baked beans, coleslaw, ice cream; supper: spaghetti and meatballs, green beans, garlic bread and fruit cup. On 1/14/26 at 1:00 PM, Resident Council was held. Six residents present who attend regularly. Residents spent greater than 20 minutes discussing food: food is cold, cold meals (sandwiches), soup not offered, bread products are too hard and you cannot eat it, especially the English muffins. Other food such as chicken tenders are so hard you cannot bite into it. Of the six residents, two were edentulous and two were missing teeth. Residents stated they do not receive a knife to cut the food. On 1/15/26 at 7:15 AM, an interview was conducted with OSM #8, the cook. Asked about what Menu week we are on, OSM #8 stated, we are on Week 3. When shown the Week 3 Menu: 1/13/26 lunch: roasted pork loin, beets, mashed potatoes, cornbread, apple crisp; supper: grilled cheese, coleslaw, cream of tomato soup and fruit cup. 1/14/26 lunch: crispy chicken thigh, capri blend vegetable, white rice and peanut butter cookie and supper: Italian sausage on bun, baked beans, roasted seasoned potatoes, diced pears; asked why the menu was not followed, OSM #8 stated, it may have been that items did not come in on the truck. Asked when truck made deliveries, OSM #8 stated, on Tuesday. I am not sure of the ordering period if it is Friday-Tuesday and Tuesday-Friday. Asked if the menu had been followed, OSM #8 stated, no, it was not. On 1/15/26 at 1:30 PM ASM (administrator staff member) #1, the administrator, RN (registered nurse) #1, the director of nursing and ASM #3, the clinical compliance specialist/acting regional was informed of the above concerns. A review of the facility's Menus policy revealed, Menus are served as written, unless changed in response to preference, unavailability of an item, or a special meal. No further information was provided prior to exit.

Based on observation, resident interview, staff interview and clinical record review, it was determined that the facility staff failed to provide palatable food for one of 38 residents, Resident #55 (R55). The findings include: The facility staff failed to provide palatable food for R55. R55 was admitted to the facility on [DATE] with diagnosis that included but were not limited to COPD (chronic obstructive pulmonary disease), diabetes mellitus and CHF (congestive heart failure).The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 12/13/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers/bathing/dressing and set-up for eating. Section L-oral/dental status-codes the resident as 'no missing teeth and edentulous-no'. A review of the comprehensive care plan dated 12/19/23 revealed, FOCUS: Resident is at risk for weight fluctuations, loss or malnutrition related to Respiratory Failure, CHF, Severe Morbid Obesity due to Excess Calories, high BMI, Lymphedema Refuses to be weighed. Requests large portion. INTERVENTIONS: Honor resident meal preference. A review of the Resident Council Minutes revealed: 7/2/25 Food is not good and is coming to rooms cold, getting the same thing, menu not posted for supper. 9/24/25 Food is served cold, Residents have commented that their meals seem overly simplistic or 'kid friendly'. 10/23/25 Food cold, do not have proper utensils. 12/11/25 Food consistently cold. An interview was conducted on 1/13/26 at approximately 11:20 AM. R55 stated, watch what we have for lunch. The food here is terrible, they do not cook a lot of the food, just sandwiches and hot dogs and they just throw the food on the plate. Observations on 1/14/26 at 8:40 AM of R55's breakfast tray revealed R55 had eaten two hard boiled eggs and was finishing his cereal. R55 stated, lift the cloche. Cloche lifted and two brown English muffins were on the plate. R55 stated, pick them up. I picked up English muffins; they were hard and unsplit. I asked R55 to hold breakfast tray and went to bring OSM (other staff member) #3, the dietary manager. OSM #3 came into R55's room with me and immediately stated, the reason he did not get scrambled eggs is because he wants hard boiled eggs. I stated, that is not why I ask you to come down here. Then asked OSM #3 to lift R55's cloche, she did and R55 stated, pick up the English muffin. OSM #3 stated, what about it? Asked if the English muffin was hard, OSM #3 stated in a loud voice, we give the residents what they want. It was not hard when it left the kitchen. I do not know how long it set undelivered on the nursing unit. I asked again if the English muffin was hard, OSM #3 stated, (in a louder voice) we make the English muffins the way the residents want them. R55 stated, it is too hard to eat. I cannot chew that, and I have my teeth. Why does the muffin not split open and toasted and then maybe some butter put on it. OSM #3 stated, you can split the muffin yourself, not everyone gets butter. OSM#3 was asked if residents who were edentulous or had missing teeth would be able to eat that English muffin, OSM #3 (loudly) stated, we are not talking about other residents, we are talking about this resident. I asked R55 how we could resolve this and he stated, toast would be fine, lightly toasted. Surveyor and OSM #3 left R55's room, ASM #2, the director of nursing and ASM #3, the clinical compliance specialist/acting regional, were outside in the hall.A test tray was done on 1/14/26 at 11:40 AM with OSM #3 and two surveyors. Menu for 1/14/26 lunch: hot dog- 107 degrees, baked beans-121 degrees, coleslaw-39 degrees, ice cream-27 degrees. Food was palatable but only warm in temperature. OSM #3 refused to test the tray with surveyors. Asked about the food temperatures, OSM #3 stated, it is hot when it leaves the kitchen, do not know how long it sits on the unit. OSM #3 was told the cart was just brought to the unit, with food being immediately served to residents. OSM #3 had no further comment. On 1/14/26 at 1:00 PM, Resident Council was held. Six residents present who attend regularly. Residents spent greater than 20 minutes discussing food: food is cold, cold meals (sandwiches), soup not offered, bread products are too hard and you cannot eat it, especially the English muffins. Other food such as chicken tenders are so hard you cannot bite into it. Of the six residents, two were edentulous and two were missing teeth. Residents stated they do not receive a knife to cut the food. On 1/14/26 at 3:30 PM ASM (administrator staff member) #1, the administrator, RN (registered nurse) #1, the director of nursing and ASM #3, the clinical compliance specialist/acting regional was informed of the above concerns. No policy for palatable food was provided. No further information was provided prior to exit.

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to maintain the kitchen in a sanitary manner. The findings include: On 1/13/26 at 10:40 AM, an observation was conducted in the kitchen with the following findings: bottom oven with dried food spills, wet nesting of two loaf pans, in dry storage room-a 25-pound bag of sugar was in bin with trash (wrappers, papers etc.), in walk in refrigerator-a tray of tuna salad sandwiches made for lunch with parchment paper laid over the top and all four sides exposed to air/elements; the chest freezer with 5 gallon vanilla ice cream carton next to raw hamburger in plastic wrap. OSM (other staff member) #3, the dietary manager accompanied surveyor on kitchen tour. An interview was conducted with OSM #3, the dietary manager as the tour was being conducted, asked about the food spill in bottom oven, OSM #3 stated, we clean the oven every other day, that must have been from yesterday. Asked about the wet nesting, OSM #3 stated, it is better to stagger them so they dry thoroughly, I will tell them. Asked about the 25-pound bag of sugar in bin with trash, OSM #3 stated, we just got our order in and they were unloading the truck and put it in there. Asked if sugar should be in bin with trash, OSM #3 stated, no. Asked about tray of sandwiches not covered, OSM #3, stated, we prepped them for lunch, if they go to the unit, we wrap them (at 11:30 AM observed OSM #8, the cook putting aluminum foil around all sides of the sandwich tray). Asked about the raw meat in freezer next to the ice cream, OSM #3 stated, was trying to figure out if I could use that meat for something. I guess I will just throw it away. On 1/14/26 at 3:30 PM ASM (administrator staff member) #1, the administrator, RN (registered nurse) #1, the director of nursing and ASM #3, the clinical compliance specialist/acting regional was informed of the above concerns.A review of the facility's Food Storage-Dry Goods policy revealed, It is the center policy to insure all dry goods will be appropriately stored in accordance with guidelines of the FDA (Food Drug Administration) Food Code. The Dining Services Director or designee ensures that all packaged and canned food items shall be kept clean, dry and properly sealed.A review of the facility's Food Storage-Cold policy revealed, The Dining Services Director or designee ensures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination.A review of the facility's Food: Preparation policy revealed, The Dining Services Director or [NAME] is responsible to ensure that all utensils, food contact equipment and food contact surfaces are cleaned and sanitized after every use.No further information was provided prior to exit.

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to dispose of refuse properly. The facility staff failed to maintain a clean dumpster area during the facility task- kitchen observation 1/13/26 at 2:10 PM. The findings include: On 1/13/26 at 2:10 PM, an observation was conducted in the dumpster area outside of the kitchen, with OSM (other staff member) #3, the dietary manager. The dumpster had both top flaps pushed all the way back. On the left side of the dumpster on the ground there was black and white gloves and diced fruit/vegetables. An interview was conducted on 1/13/26 at 2:10 PM with OSM #3, the dietary manager. When asked about the findings, OSM #3 stated, they will come pick up the trash today and then the area is swept. When asked about the dumpster not being covered, OSM #3 stated, well they are bringing trash out all the time from the kitchen and the resident areas. It is hard to reach to close the flaps. On 1/14/26 at 3:30 PM ASM (administrator staff member) #1, the administrator, RN (registered nurse) #1, the director of nursing and ASM #3, the clinical compliance specialist/acting regional was informed of the above concerns.A review of the facility's Dispose of Garbage and Refuse policy revealed It is the center policy-all garbage and refuse will collect and disposed of in a safe and efficient manner. The Dining Services Director coordinates with the Director of Maintenance to ensure that the area surrounding the exterior dumpster area is maintained in a manner free of rubbish or other debris.No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide hospice visits and required documentation per the plan of care for one of thirty-eight residents in the survey sample (Resident #74).The findings include:Resident #74's hospice failed to provide services and documentation as required in the plan of care.Resident #74 (R74) was admitted to the facility with diagnoses that included atherosclerosis, diabetes, lung cancer, adult failure to thrive, protein-calorie malnutrition, chronic kidney disease, major depressive disorder, dementia, psychotic disturbance, mood disturbance, anxiety, and insomnia. The minimum data set (MDS) dated [DATE] assessed R74 with severely impaired cognitive skills.R74's clinical record documented a physician's order for hospice services dated 4/26/24. R74's plan of care (revised 11/5/25) documented the resident received hospice services due to a cancer diagnosis. The plan of care interventions to provide comfort and end of life needs included, Follow Hospice orders .Refer to hospice as needed .See hospice plan of care . The plan of care included the contracted hospice service contact information.R74's hospice plan of care (updated 7/27/24) included problems, goals and interventions to address altered mental status, pain/comfort, spiritual needs, safety, neurological status, cardiovascular concerns and listed equipment needed/provided. The hospice plan of care documented services/needs were met with the following visits: skilled nurse visit once per week and 3 additional visits per week as needed; hospice aide visits twice per week; social worker visit once per month; and chaplain visit once per month with 3 additional visits per month as needed.Review of R74's clinical record revealed hospice orders were included in the resident's care and were implemented as ordered. R74's clinical record revealed no documentation of any visits by a hospice nurse, hospice aide, hospice social worker or the hospice chaplain as listed in the plan of care.On 1/14/26 at 1:16 p.m., the licensed practical nurse unit manager (LPN #2) caring for R74 was interviewed about hospice services for R74. LPN #2 stated R74 had hospice orders and a hospice plan of care. LPN #2 stated hospice nurses/aides usually left notes in a designated book at the desk after their visits. LPN #2 looked at the nursing desk and found no designated book for R74's hospice provider. LPN #2 stated nurses called the hospice as needed and that orders were entered as provided. LPN #2 stated she had no notes from nurse or aide visits from R74's hospice provider. LPN #2 stated hospice nurses come when we call them but she did not recall routine visits. LPN #2 stated she had not seen hospice aides in the facility from this hospice service. LPN #2 stated, I can't say that a CNA [certified nurse's aide] has come. On 1/14/26 at 3:08 p.m., the director of nursing (DON) was interviewed about any record of visits by R74's hospice service. The DON stated she did not find any hospice notes in R74's clinical record. The DON checked with medical records and stated no visit notes for R74 had been provided by the hospice agency.On 1/15/26 at 8:15 a.m., the DON stated, upon request, R74's hospice provider had sent copies of visit notes since 2024. Documentation from R74's hospice since 11/1/25 listed two nurse practitioner visits, one skilled nurse visit, two hospice aide visits; no social worker visits and no chaplain visits.The hospice contract with R74's hospice provider was reviewed. The inpatient services agreement was dated 7/7/25, had an effective date of 7/15/25 and documented on page 12, .The Hospice agrees to provide services to hospice patients according to a Hospice Plan of Care .If the Hospice Plan of Care calls for nursing, home health care aide, social work, counseling, trained volunteers, spiritual counseling, physician, or other services related to the management of the terminal illness, the Hospice shall provide such services . Page 13 of this agreement documented, .All members of the Hospice IDG [interdisciplinary group] will document their care and services provided at each visit to the hospice patient. Documentation is placed in the Nursing Facility's patient chart; a copy shall be maintained in the Hospice medical record. The Hospice Medical Director and Hospice IDG reviews the Hospice Plan of Care at the IDG meetings and approves the Hospice Plan of Care through their signatures .This finding was reviewed with the administrator, DON and regional nurse consultant on 1/14/26 at 3:30 p.m. and on 1/15/26 at 10:15 a.m. with no further information presented prior to the end of the survey.

Based on observation and facility document review, the facility staff failed to ensure medications used in the facility were within expiration date for 1 of 2 medication storage rooms (South Unit).Findings include:The facility staff failed to ensure two medications were within expiration date in the medication room on the South Unit.On [DATE], an inspection of the Medication Room on South Unit was completed with LPN#1 revealing one bottle of Geri Dryl Allergy Relief Liquid with expiration date 4/2025 and one tube of Venelex Wound Dressing (a combination of [NAME] and castor oil used to treat wounds) with an expiration date 2/2025. When LPN#1 was given the 2 medications with expired dates, she stated these need to be discarded as they are expired.Review of the facility policy# 4.1, entitled Storage of Medications 8. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal.On [DATE], at the end of day, the Administrator (ADM#1) and Director of Nursing (RN#1) were made aware of the concerns, and no further information was provided.

Based on observations, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care services for one of 38 residents, Resident #109 (R109). The findings include: The facility staff failed to provide respiratory therapy per physician orders for R109. R109 was admitted to the facility on [DATE] with diagnosis that included but were not limited to chronic respiratory failure, atrial fibrillation and CHF (congestive heart failure).The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 1/1/26, coded the resident as scoring an 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring moderate assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of the comprehensive care plan dated 12/24/25 revealed, FOCUS: RESPIRATORY: the resident is at risk for respiratory complications secondary to COPD, respiratory failure, supplementary oxygen requirement and history of Pneumonia., congestion. INTERVENTIONS: administer oxygen as ordered. Observations on 1/13/26 at 11:51 AM, 1/13/26 at 3:45 PM and 1/14/26 at 7:10 AM indicated the oxygen was set at 3 liters per minute. A review of the physician orders dated 1/12/26 revealed, Oxygen Therapy - Oxygen at (2) liters per minute via nasal cannula. A review of the January TAR (treatment administration record) revealed, Oxygen at 2 liters per minute initialed for 1/13/26 day, evening and night shift. A review of the progress note dated 1/14/26 at 1:13 PM revealed, Resident has an O2 order for 2L/m nasal cannula. However, resident's 02 was changed by family member to 3L/m. Family member was informed of the doctor's order and the O2 was changed to the correct order 2L/m. Resident currently HAS AN O2 reading of 97% via nasal cannula. An interview was conducted on 1/14/26 at 8:30 AM with RN (registered nurse) #3. Asked to observe R109's oxygen level, RN #3 stated, it is at 3lnc. I will check the orders. It is ordered for 2lnc. I will change it now. On 1/14/26 at 3:30 PM ASM (administrator staff member) #1, the administrator, RN (registered nurse) #1, the director of nursing and ASM #3, the clinical compliance specialist/acting regional was informed of the above concerns.A review of the facility's Respiratory Care & Oxygen Equipment policy revealed Oxygen therapy will be administered per provider's order. No further information was provided prior to exit.

Based on observations, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to promote dignity and respect for one of 38 residents, Resident #55 (R55). The findings include: The facility staff failed to promote dignity and respect for R55. R55 was admitted to the facility on [DATE] with diagnosis that included but were not limited to COPD (chronic obstructive pulmonary disease), diabetes mellitus and CHF (congestive heart failure).The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 12/13/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers/bathing/dressing and set-up for eating. Section L-oral/dental status-codes the resident as 'no missing teeth and edentulous-no'. A review of the comprehensive care plan dated 12/19/23 revealed, FOCUS: Resident is at risk for weight fluctuations, loss or malnutrition related to Respiratory Failure, CHF, Severe Morbid Obesity due to Excess Calories, high BMI, Lymphedema Refuses to be weighed. Requests large portion. INTERVENTIONS: Honor resident meal preference.Observations on 1/14/26 at 8:40 AM of R55's breakfast tray revealed R55 had eaten two hard boiled eggs and was finishing his cereal. R55 stated, lift the cloche. Cloche lifted and two brown English muffins were on the plate. R55 stated, pick them up. I picked up English muffins; they were hard and unsplit. I asked R55 to hold breakfast tray and went to bring OSM (other staff member) #3, the dietary manager. OSM #3 came into R55's room with me and immediately stated, the reason he did not get scrambled eggs is because he wants hard boiled eggs. I stated, that is not why I ask you to come down here. Then asked OSM #3 to lift R55's cloche, she did and R55 stated, pick up the English muffin. OSM #3 stated, what about it? Asked if the English muffin was hard, OSM #3 stated in a loud voice, we give the residents what they want. It was not hard when it left the kitchen. I do not know how long it set undelivered on the nursing unit. I asked again if the English muffin was hard, OSM #3 stated, (in a louder voice) we make the English muffins the way the residents want them. R55 stated, it is too hard to eat. I cannot chew that, and I have my teeth. Why does the muffin not split open and toasted and then maybe some butter put on it. OSM #3 stated, you can split the muffin yourself, not everyone gets butter. OSM#3 was asked if residents who were edentulous or had missing teeth would be able to eat that English muffin, OSM #3 (loudly) stated, we are not talking about other residents, we are talking about this resident. I asked R55 how we could resolve this and he stated, toast would be fine, lightly toasted. Surveyor and OSM #3 left R55's room, ASM #2, the director of nursing and ASM #3, the clinical compliance specialist/acting regional, were outside in the hall.On 1/14/26 at 10:30 AM, surveyor returned to R55's room. R55 stated, they were able to find you. I stated, no, I was returning to his room to follow up regarding meal. R55 stated, what happened before was b--- s---. She tried to intimidate you and tried to intimidate me. She was so defensive and came into the room that way, talking about the eggs before you could even say anything. R55 was asked if he felt respected and treated with dignity during the interaction with OSM #3, R55 stated, no, I was not shown respect. That was not right for her to talk that way.When relaying this information to ASM #3 during end of day, ASM #3 stated, you looked shocked when you came out of the room and if I had heard OSM #3 talking like that, I would have intervened. That was not respectful.On 1/14/26 at 3:30 PM ASM (administrator staff member) #1, the administrator, RN (registered nurse) #1, the director of nursing and ASM #3, the clinical compliance specialist/acting regional was informed of the above concerns.A review of the facility's Resident's Rights Annual Review policy revealed, To be free from verbal abuse. To be treated with consideration, respect and full recognition of his/her dignity and individuality.No further information was provided prior to exit.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to provide a comfortable, homelike room environment for one of thirty-eight residents in the survey sample (Resident #26).The findings include:The heat unit in Resident #26's room had not been functioning properly for several weeks.Resident #26 (R26) was admitted to the facility with diagnoses that included dysarthria, lymphoma, diabetes, major depressive disorder, hypertension, hyperlipidemia and cerebral infarction. The minimum data set (MDS) dated [DATE] assessed R26 as cognitively intact.On 1/13/26 at 10:47 a.m., R26 was interviewed about quality of care/life in the facility. R26 stated during this interview that the heat unit in his room was not working properly and had been dysfunctional for the last several weeks. R26 stated the unit ran but then went to blowing cold air. R26 stated at times the room temperature was cool because the heat did not stay on. The heat unit was turned off at the time of the interview. The room temperature did not feel noticeably cool/cold. R26 turned on the heat using the wall thermostat and the unit fan began running. The unit ran for approximately two minutes with cool air felt blowing from the unit. R26 turned off the unit after a couple of minutes and stated that the unit just blew cold air. R26 stated he had previously reported the dysfunctional heat unit to nursing several times and was told they would make a note of it. R26 stated maintenance had not worked on the unit and he did not recall the names of those he told about the heat unit.On 1/13/26 at 4:18 p.m. the administrator was interviewed about R26's room heat. The administrator stated she was not aware of the problem with R26's heat unit.On 1/14/26 at 8:02 a.m., the maintenance director (other staff #2) was observed working on R26's heat unit. The maintenance director was interviewed at this time about the unit. The maintenance director stated he was asked yesterday (1/13/26) to check the unit. The maintenance director stated he reset the unit yesterday (1/13/26) and the heat kicked in. The maintenance director stated the unit did not stay functioning and was not producing heat this morning (1/14/26). The maintenance director stated he was not sure what was wrong with the unit. The maintenance director stated he was not aware the unit was not working properly until 1/13/26. The maintenance director stated he had received no verbal reports or work orders for the heat unit prior to 1/13/26. The maintenance director stated the heat units in the facility were old and they were in the process of replacing the units throughout the facility. On 1/14/26 at 9:59 a.m., the licensed practical nurse unit manager (LPN #2) caring for R26 was interviewed. LPN #2 stated nobody had reported to her any problem with R26's heat unit. LPN #2 stated if she was aware the unit was not working properly, she would have reported it to maintenance.On 1/14/26 at 10:12 a.m., registered nurse (RN #2), assigned to management rounding that included R26's room, was interviewed. RN #2 stated she had performed daily rounds in R26's room for the last month. RN #2 stated she never noticed the room as cold and that R26 never mentioned to her any problems with the heat. RN #2 stated if she had known of a heat problem, she would have reported it to maintenance.This finding was reviewed with the administrator and director of nursing during a meeting on 1/14/26 at 3:30 p.m. with no further information presented prior to the end of the survey.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to maintain a safe room environment for one of thirty-eight residents in the survey sample (Resident #26).The findings include:A portable electric heater was in use in Resident #26's room.Resident #26 (R26) was admitted to the facility with diagnoses that included dysarthria, lymphoma, diabetes, major depressive disorder, hypertension, hyperlipidemia and cerebral infarction. The minimum data set (MDS) dated [DATE] assessed R26 as cognitively intact.On 1/13/26 at 10:47 a.m., R26 was interviewed about quality of care/life in the facility. R26 stated during this interview that the heat unit in his room was not working properly and had been dysfunctional for the last several weeks. R26 stated the unit ran but then went to blowing cold air. R26 stated at times the room temperature was cool because the heat did not stay on. R26 stated he had reported the dysfunctional heat unit to nursing several times and was told they would make a note of it. R26 stated maintenance had not worked on the unit and he did not recall the names of those he told about the heat. R26 stated he was using an electric heater when the room got cool. A small electric heater was observed at this time on the floor beside the resident's bed. The unit was running with a small amount of warm air blowing from the unit. R26 stated he did not think that staff knew he was running the heater. R26 stated he purchased the unit from Amazon about a year ago and that staff had informed him not to use the heater because it was some kind of safety issue. R26 stated he had used the heater in the last several weeks when the room felt cool. R26 stated he was aware that the electric heater was not allowed. R26 stated again he did not think staff were aware he was running the heater.Review of R26's clinical record revealed no documentation of reported issues with the room heat during the last several weeks.The survey team contacted the state agency supervisor about the observed heater who then notified state life safety code officials. On 1/13/26 at 1:00 p.m., a life safety code surveyor came to the facility, removed the heater from R26's room and reported the issue to the maintenance director.On 1/13/26 at 4:18 p.m., the administrator was interviewed about R26's room heat. The administrator stated she was not aware of the problem with R26's heat unit or that the resident had been using an electric heater.On 1/14/26 at 8:02 a.m., the maintenance director (other staff #2) was observed working on R26's heat unit. The maintenance director stated he was not aware the unit was not working properly until 1/13/26. The maintenance director stated he had received no verbal reports or work orders for the heat unit prior to 1/13/26. The maintenance director stated space heaters were not allowed in resident areas and that he was not aware that R26 had purchased or was running the electric heater until notification on 1/13/26.On 1/14/26 at 9:59 a.m., the licensed practical nurse unit manager (LPN #2) caring for R26 was interviewed. LPN #2 stated nobody reported to her any problem with R26's heat. LPN #2 stated if she was aware the unit was not working properly, she would have reported it to maintenance. LPN #2 stated she was not aware R26 was running an electric heater in his room.On 1/14/26 at 10:12 a.m., registered nurse (RN #2), assigned to management rounding that included R26's room, was interviewed. RN #2 stated she had performed daily rounds in R26's room for the last month. RN #2 stated her rounds included observing the resident's room and talking with the resident about any issues/concerns. RN #2 stated she had not seen the electric heater in the R26's room and that the resident had not mentioned a heat issue. RN #2 stated if she had known of a heat problem, she would have reported it to maintenance.On 1/14/26 at 1:05 p.m., the certified nurse's aide (CNA #2) that routinely cared for R26 was interviewed. CNA #2 stated she had not seen an electric heater in R26's room and was not aware of a heat issue. CNA #2 stated R26 was independent with most activities of daily living. CNA #2 stated she provided a water basin and linens for the resident daily and that the resident performed his own bathing and hygiene. CNA #2 stated she had not noticed the room as cool or cold and again stated she had not seen the electric heater when in the resident's room.On 1/14/26 at 1:12 p.m., LPN #3 caring for R26 was interviewed. LPN #3 stated she had not cared for R26 until today. LPN #3 stated she had never seen electric heaters in use in any resident rooms.On 1/14/26 at 2:39 p.m., the maintenance director (other staff #2) was interviewed again about the electric heater observed in R26's room. The maintenance director stated he did not know about the heater until yesterday (1/13/26). The maintenance director stated that space heaters were not allowed in resident use areas. The maintenance director stated that life safety code regulations prohibited the use of space heaters in resident living/use areas.This finding was reviewed with the administrator, director of nursing and regional nurse consultant on 1/14/26 at 3:30 p.m. with no further information presented prior to the end of the survey.

Based on staff interview, facility document review and clinical record review, the facility staff failed to document a clinical rationale for denial of a recommended dose reduction for one of thirty-eight residents in the survey sample (Resident #74).The findings include: Resident #74's physician failed to document a clinical rationale for a denied dose reduction of a psychoactive medication.Resident #74 (R74) was admitted to the facility with diagnoses that included atherosclerosis, diabetes, lung cancer, adult failure to thrive, protein-calorie malnutrition, chronic kidney disease, major depressive disorder, dementia, psychotic disturbance, mood disturbance, anxiety, and insomnia. The minimum data set (MDS) dated [DATE] assessed R74 with severely impaired cognitive skills.R74's clinical record documented a physician's order dated 4/9/25 for the antidepressant trazodone 50 milligrams (mg) given at each bedtime for treatment of insomnia. R74's medication administration record documented trazodone was administered at 9:00 p.m. each evening as ordered.R74's clinical record included a Consultant Pharmacist Recommendation to Physician form dated 10/25/25. The recommendation documented was, .Federal guidelines state antidepressant drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with 1 month between attempts, then annually thereafter .This resident has been taking TRAZODONE 50 MG Q HS [at bedtime] since 4/9/25 without a GDR. Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose? If not, please indicate response below .The physician responded to the pharmacy recommendation on 11/10/25 and indicated to continue the trazodone 50 mg and listed no reasons why the dose reduction was contraindicated at this time. A physician progress note dated 11/10/25 listed a review of the resident regarding a possible dose reduction for the trazodone. This note documented, .d/w [discussed with] nurse .her seroquel was recently stopped .she needs trazodone .its a low dose anyway .will continue to monitor at present dose . The note listed no clinical contraindication regarding the recommended dose reduction.On 1/14/26 at 2:48 p.m., the licensed practical nurse unit manager (LPN #2) caring for R74 was interviewed about the pharmacy recommendation. LPN #2 stated the physician did not document why he did not approve the dose reduction on the pharmacy recommendation form. LPN #2 reviewed the clinical record and stated the physician documented a progress note on 11/10/25 recommending to continue the 50 mg dose.On 1/14/26 at 3:03 p.m., the director of nursing (DON) was interviewed about a rationale regarding R74's recommended dose reductions. The DON stated the physician was supposed to respond to the recommended dose reduction and indicate on the form the reason or contraindications if the dose reduction was denied. The DON presented no other information about the rationale for not attempting the dose reduction.The facility's policy titled Medication Management (effective 08-2020) documented, .In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use . This policy documented regarding psychopharmacologic medications, .The GDR is considered clinically contraindicated if .Target symptoms returned or worsened after the most recent attempt at a GDR and the physician documents the clinical rationale for why any additional attempted dose reductions would likely impair the resident's function, increase distressed behavior, or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder, OR .The continued use is in accordance with relevant current standards of practice and the physician document the clinical rationale for why any additional attempted dose reductions would likely impair the resident's function, increase distressed behavior, or cause psychiatric instability by exacerbating and underlying medical or psychiatric disorder . (sic)This finding was reviewed with the administrator and DON on 1/24/26 at 3:30 p.m. with no further information provided prior to the end of the survey.

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure residents were free from accidents and hazards for 3 Residents (#'s 114, 59, and 65) in a survey sample of 55 residents. The Findings included:1. For Resident #114 the facility staff failed to provide adequate supervision to prevent the residents from eloping from the facility.Resident #114 was admitted to the facility on [DATE] with diagnoses that included but were not limited to pancreatic cancer, bile duct obstruction, palliative care, chronic bronchitis, muscle weakness, depression, general anxiety disorder, insomnia due to medical condition, psychotic disorder with hallucinations due to a known physiological condition (paranoid schizophrenia), and psychotic disorder with delusions due to a known physiological condition (paranoid schizophrenia).Resident #114's most recent BIMS (Brief Interview of Mental Status) scored the Resident at 15/15 indicating no cognitive impairment. Resident #114's clinical record included a document entitled Provider Attestation for Schizophrenia/Schizoaffective/Schizophreniform Diagnosis that listed the medications for this diagnosis as Seroquel ER 150 mg per day, Depakote 500 mg 2 times daily and Haldol 10 mg 2 times daily. All meds read for diagnosis of Psychotic disorder with hallucinations due to a known physiological illness.On 7/14/25 at approximately 1:30 p.m. Residents were observed sitting in front of the building without supervision from staff. On 7/15/25- 7/17/25 at various times throughout the day residents were observed without supervision, outdoors in front of the building in wheelchairs or independently ambulating. Supervision was provided to Residents in the gazebo smoking, and fluids were provided to the residents at the exit door on south hall that leads to the gazebo. No supervision or fluids were being offered at the front main entrance. A review of the clinical record revealed the following excerpts: 6/13/24 7:25 p.m. Resident was involved in a verbal/physical altercation with another resident in which Mr. V. [NAME] pushed [Resident name redacted] on her right shoulder, grabbed her right leg, stomped her glasses and kicked her phone in the grass. Writer questioned Resident about the incident, and he stated that she triggered him by saying what she said to him. 6/26/24 6:12 am. - On this date 06/12/2024 during my shift, resident was seen going out of the facility 0540, when asked where he was going, resident says what kind of question are you asking me, I want to get a cigarette lighter at nearby store. All effort to redirect him back to the facility was prove abortive until a staff followed him and drove him back to the facility. 6/29/24 5:16 - Resident was noted to be seen by staff at 0130. Staff went to resident room to check on him and he was nowhere to be found. Resident apparently had left the building unbeknownst to staff. Staff immediately did a sweep of the interior and exterior of the facility unable to locate Mr. [NAME]. Police were called and given a picture and description of the clothing the resident was wearing when last seen. Staff notified DON, RP and provider. Officers spoke with other officers in a different jurisdiction which stated they had him at [Convenience store name redacted] Staff was [sic] told by officers they would have to transport [Resident 114 name redacted] back to facility 6/29/24 5:58 a.m. - This writer saw resident at 0130 entered the dining room and later went to resident room to check on him and he was nowhere to be found. Resident had walk [sic] away from the building unknown to staff. Sweeping of the interior and exterior of the facility was done still unable to find [Resident #114 name redacted] Police were called and given a picture and description of the clothing the resident was wearing when last seen. DON was notified, RP and provider. Officers spoke with other officers in a different jurisdiction which stated they found him at [convenience store name redacted]. Staff was [sic] told by officers they would have to transport [Resident#114 name redacted] back to facility. Staff drove to the location where he was found (approximately 7.1 miles away from the facility) and bring [sic] him back to the facility. Head to toe Skin assessment was done and intact. Resident was later sent out to hospital for psych consult EMS notified and resident was transported to the hospital by 2 EMS at 535. 7/2/24 9:30 a.m.- I was able to find legal Guardian's phone number. I called her to speak about resident's wander guard. She said that resident has a history of wandering, and she would really appreciate him having a wander guard. She asked if it had a tracking device, and I explained that it only alerted us when he went out the building. She said that it was fine and appreciated the call.On 7/16/24 at approximately 11:45 a.m. an interview was conducted with the Administrator; she was asked why the first incidents of elopement were not reported to the OLC and other entities as required by CMS Guidelines. The Administrator stated that Resident #114 had a High BIMS score and therefore he could leave the facility if he signed himself out. She stated that he had scored high on his BIMS and then eloped. She stated that he did not sign himself out of the facility. The Administrator was asked if Resident #114 had Any conditions that would affect his decision-making ability, she stated that he had a diagnosis of Schizophrenia.On the afternoon of 7/17/25 an interview was conducted with Employee L who was asked if a Resident with a BIMS of 15 can leave the facility unescorted, Employee L stated that it would depend on the physical and mental state of the Resident. When asked if BIMS alone could determine the ability of a Resident to leave the facility unescorted and she stated the BIMS was only one piece of the equation. Employee L stated that the Resident must be safe to ambulate independently and able to make safe decisions and notify the facility when he or she is leaving the facility. She stated that the RP must also be aware of the residents leaving the facility. Employee L also stated that the LOA (Leave of Absence) form must be signed prior to leaving the facility.A review of the policy entitled Leave of Absence Policy revealed the following: When a patient leaves the center for reasons other than a medical transfer initiated by the center, the patient and or responsible party will provide signature, accept complete responsibility of the patient and absolving the management, personnel and the attending physician of responsibility for any deterioration in condition or accident that may happen while the patient is away.1. Before a patient leaves the premises for any reason, other than medical transfer initiat3ed by the center, the patient and or responsible party must notify a licensed nurse on the unit.2. A licensed nurse ensures that medical approval of the leave has been provided by the patient's provider.3. The Release of Responsibility for Leave of Absence (LOA) form is filled out prior to leaving the center, the date and time and signature of the person accepting responsibility is filled in 4. The estimated time of return is provided to a licensed nurse. A review of the clinical record revealed that the Resident was not his own RP, and his Guardian did not wish him to leave the facility unescorted, and she had not filled out a Release of Responsibility form.On 7/18/25 the Administrator was made aware of the concerns, and no further information was provided.2. For Resident #59, the facility staff failed to provide adequate supervision to prevent Resident #59 from falling while in the parking lot.Resident #59 was admitted to the facility on [DATE] with diagnoses that included but were not limited to injury of bladder, type 2 diabetes, difficulty walking, cerebral ischemia, fractured pelvis, chronic viral hepatitis, muscle weakness, subdural hemorrhage, sepsis, anemia, major depressive disorder, insomnia, retinal artery occlusion to right eye (causing blindness) and bilateral cataracts. Resident #59's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6-20-25 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 14/15 indicating no cognitive impairment. Section G (Functional Status) coded the resident as requiring (3) Extensive Mobility with (2) One-person physical assistance for bed mobility, (4) Total assistance with (2) one-person physical assistance for bed mobility and (4) Total assistance with (2) one-person physical assistance for toileting.On 7/15/25 at approximately 12:55 p.m. an interview was conducted with Resident #59 who stated that she had a fall in the parking lot on 7/11/25. She stated that the CNA brought her out so that she could get some fresh air and that she was left unattended outside. She stated that she wanted to go see the gazebo, so she attempted to wheel herself down the sidewalk to the gazebo. However, she stated that she lost control of her wheelchair and went over the curb and fell and the wheelchair fell on top of her. She stated that she did not get injured and the staff responded, pretty quickly. When asked if she continues to go outside since the fall, she stated that she does. She stated that she does not venture away from the front doors anymore without assistance. When asked how she would get assistance if she needed help, she stated that she would have to go inside and ask for help or wait for staff to come outside.OT Consult dated 6/16/25 read: Pt presents with max A [assistance] x2 for bed mobility, max A x2 for lateral scooting along EOB [edge of bed] and transfers. Total A for lower body ADL's and set up to supervision for support3ed sitting upper body ADLs, Mod A at trunk for dynamic activity. Patient primarily limited by sitting Balance deficits, BLE (Bilateral Lower Extremity) weakness, impairing functional mobility, fine motor coordination deficits, global deconditioning, impaired activity tolerance, increased fall risk, need for increased time to complete tasks, preexisting injuries /ROM limitations which are severely impacting their ability to independently complete ADL's. 7/11/25 3:27 p.m. - Description of the fall/V/S/injuries if any: Phone call made to unit to notify staff that resident was on the ground outside. Nursing staff ran to front entrance and outside, observed resident wheelchair in between 2 cars at the front of the building. Resident noted laying on right with wheelchair on top of her. Resident assessed and placed back into chair by staff. Resident states she was trying to wheel herself to the gazebo. Resident states she was wheeling herself and lost control, and went over the curb. V/S 90/58-73-73-18-97.8-97% What Interventions were in place at the time of the fall? Resident in wheelchair wheels locked. What are the risk factors that could have contributed to the fall? Resident propelling self without assistance What new Interventions were implemented in response to the fall? Educate resident to ask for assistance when propelling wheelchair on uneven surfaces. Was the Provider/resident and RP notified at the time of the fall? yes, NP and daughter notified.‘7/12/25 7:28 a.m. - LATE ENTRY Situation : Date and time the fall occurred: 07/11/2025 12:00 PM Background : Circumstances of the fall: resident was propelling outside in wheelchair unassisted Assessment (RN)/Appearance (LPN) : Current status of the resident's injuries or reports of pain from the fall: no injuries or pain reported Recommendation : Interventions currently in place to prevent additional falls: resident to ask for assistance when propelling on uneven surfaces. 7/15/25 1:00 p.m. - Patient was seen for follow- up psychotherapy session for monitoring and treatment of mental health symptoms. Patient was located outside and agreed to engage in session. Client details of fall she had outside of the facility, stating she was embarrassed, so happy she did not hurt herself.On 7/20/25 at approximately 2:00 p.m. an interview was conducted with the DON who was asked if fall assessments are a part of the admission process and she stated that they were. When asked how often they are done she stated that they are done on admission, quarterly and after any falls A review of the clinical record revealed there was no fall assessment completed until 7/11/25 after the resident had the fall on 7/11/25. The fall assessment coded Resident #59 as being a moderate fall risk.On 7/20/25 during the end-of-day meeting the Administrator was made aware of the concerns and no further information was provided.2. For Resident #65, the facility failed to provide appropriate and sufficient supervision to prevent the risk of potential accident hazards as evidenced by observing 2 pills on the floor near other residents exhibiting wandering behaviors. Resident #65 was admitted to the facility 7/30/2024 with diagnoses including but not limited to: lumbar spinal bifida with hydrocephalus, paraplegia, immunodeficiency, neurogenic bowel, neuromuscular dysfunction, constipation and mood disorder due to known physiological condition with major depression-like episode.On the most recent MDS (Minimum Data Set) an annual assessment with ARD (assessment reference date) of 5/28/2025, Section C: Cognitive Patterns was coded as 15 out of a possible score of 15 indicating no cognitive impairment.On 07/16/2025 at 10:00 am during interview with Resident #65, 2 tablets were observed on the floor under the bedside table: one (1) round orange and one (1) round white tablet with scuff marks. The Resident stated she didn't know how long they had been there. On 7/16/2025 at 10:15am LPN-B was notified of the tablets on the floor. An inspection of the medication cart and review of Resident #65's Physician's orders and Medication Administration Record (MAR) was completed to identify the 2 tablets.The Medication Administration Record (MAR) revealed an order for Senokot 8.6 mg. 3 tablets every 24 hours (round orange) and was documented as being given July 2 - July 15.On July 1 the MAR revealed the resident refused Senokot and an order for Acetaminophen ES PRN (white round) with no documentation on the MAR for [DATE] as being administered. On 7/16/2025 at approximately 10:30am Employee C was interviewed, and she stated she had entered the room after Resident #65 and surveyor had exited to clean the room, she stated the room always smells so bad that she cleans as quick as she can. Further interview with Employee C what she would do if she saw pills on the floor she replied, I would sweep them up and throw them in the trash can.On 7/16/25 at 10:44 am the Director of Nursing was interviewed on what her expectations for the nurse in administering medications to residents would be and she replied, to ensure they swallow their medications.On 7/17/2025, a list of residents who self-administer medications was requested by the Administrator. The list did not contain Resident #65's name as self-administering her medications.On 7/21/ 2025 at 11:43 am LPN-B was interviewed regarding whether she had any residents on her unit with wandering behavior and she said Oh, maybe [Resident #70 name redacted] might wander up and down hallOn 7/21/2025 at 11:47 am C.N.A-B was interviewed on whether she was aware of any residents on her unit exhibiting wandering behaviors and she said [Resident #70 name redacted] sometimes wanders up and down halls he goes to the end of hall because he wants to go out outside but he doesn't go in other residents rooms just goes to the end of the hall where the door is.On 7/20/2025 at 12:02 pm an interview was conducted with C.N.A-C on whether she had any residents on her unit who exhibited wandering behaviors, and she stated, I don't know of anyone that wanders.Resident #70 was admitted to the facility on [DATE] with diagnoses including but not limited to traumatic subdural hemorrhage without loss of consciousness and unspecified dementia. MDS ARD State Optional 7/15/25 Section C: Cognitive Patterns coded as 3 out of a possible score of 15 indicating severe cognitive impairment. Record review for Resident #70's progress notes dated 7/17/25 at 16:46 by the Nurse Practitioner; [Resident #70 name redacted] is being seen and followed up today for increased confusion in the setting of advanced dementia. The residence remains confused at baseline. He is normally easily redirected. The nursing staff reports that he has been more and has been wandering more through the facility. He needs more frequent redirection. The nursing staff has a wander guard in place to prevent elopement from the facility.Resident #70 resided in a room near the room where the tablets were observed on the floor.Review of facility document Policy #8.2 General Guidelines for Medication Administration 17. The resident is always observed after administration to ensure that the dose was completely ingested.No further information and/or documentation was presented prior to the exit conference on 07/22/2025. 3. For Resident #65, the facility failed to provide appropriate and sufficient supervision to prevent the risk of potential accident hazards as evidenced by observing 2 pills on the floor near other residents exhibiting wandering behaviors.Resident #65 was admitted to the facility 7/30/2024 with diagnoses including but not limited to: lumbar spinal bifida with hydrocephalus, paraplegia, immunodeficiency, neurogenic bowel, neuromuscular dysfunction, constipation and mood disorder due to known physiological condition with major depression-like episode.On the most recent MDS (Minimum Data Set) an annual assessment with ARD (assessment reference date) of 5/28/2025, Section C: Cognitive Patterns was coded as 15 out of a possible score of 15 indicating no cognitive impairment.On 07/16/2025 at 10:00 am during interview with Resident #65, 2 tablets were observed on the floor under the bedside table: one (1) round orange and one (1) round white tablet with scuff marks. The Resident stated she didn't know how long they had been there. On 7/16/2025 at 10:15am LPN-B was notified of the tablets on the floor. An inspection of the medication cart and review of Resident #65's Physician's orders and Medication Administration Record (MAR) was completed to identify the 2 tablets.The Medication Administration Record (MAR) revealed an order for Senokot 8.6 mg. 3 tablets every 24 hours (round orange) and was documented as being given July 2 - July 15.On July 1 the MAR revealed the resident refused Senokot and an order for Acetaminophen ES PRN (white round) with no documentation on the MAR for [DATE] as being administered. On 7/16/2025 at approximately 10:30am Employee C was interviewed, and she stated she had entered the room after Resident #65 and surveyor had exited to clean the room, she stated the room always smells so bad that she cleans as quick as she can. Further interview with Employee C what she would do if she saw pills on the floor she replied, I would sweep them up and throw them in the trash can.On 7/16/25 at 10:44 am the Director of Nursing was interviewed on what her expectations for the nurse in administering medications to residents would be and she replied, to ensure they swallow their medications.On 7/17/2025, a list of residents who self-administer medications was requested by the Administrator. The list did not contain Resident #65's name as self-administering her medications.On 7/21/ 2025 at 11:43 am LPN-B was interviewed regarding whether she had any residents on her unit with wandering behavior and she said Oh, maybe [Resident #70 name redacted] might wander up and down hallOn 7/21/2025 at 11:47 am C.N.A-B was interviewed on whether she was aware of any residents on her unit exhibiting wandering behaviors and she said [Resident #70 name redacted] sometimes wanders up and down halls he goes to the end of hall because he wants to go out outside but he doesn't go in other residents rooms just goes to the end of the hall where the door is.On 7/20/2025 at 12:02 pm an interview was conducted with C.N.A-C on whether she had any residents on her unit who exhibited wandering behaviors, and she stated, I don't know of anyone that wanders.Resident #70 was admitted to the facility on [DATE] with diagnoses including but not limited to traumatic subdural hemorrhage without loss of consciousness and unspecified dementia. MDS ARD State Optional 7/15/25 Section C: Cognitive Patterns coded as 3 out of a possible score of 15 indicating severe cognitive impairment. Record review for Resident #70's progress notes dated 7/17/25 at 16:46 by the Nurse Practitioner; [Resident #70 name redacted] is being seen and followed up today for increased confusion in the setting of advanced dementia. The residence remains confused at baseline. He is normally easily redirected. The nursing staff reports that he has been more and has been wandering more through the facility. He needs more frequent redirection. The nursing staff has a wander guard in place to prevent elopement from the facility.Resident #70 resided in a room near the room where the tablets were observed on the floor.Review of facility document Policy #8.2 General Guidelines for Medication Administration 17. The resident is always observed after administration to ensure that the dose was completely ingested.No further information and/or documentation was presented prior to the exit conference on 07/22/2025.

Based on interview, clinical record review, and facility documentation, the facility staff failed to report allegations of abuse or neglect for 1 Resident (#114) in a survey sample of 55 Residents.The findings included: For Resident #114, the facility staff failed to report the resident eloping from the facility on several occasions. Resident #114 was admitted to the facility on [DATE] with diagnoses that included but were not limited to pancreatic cancer, bile duct obstruction, palliative care, chronic bronchitis, muscle weakness, depression, general anxiety disorder, insomnia due to medical condition, psychotic disorder with hallucinations due to a known physiological condition (paranoid schizophrenia), and psychotic disorder with delusions due to a known physiological condition (paranoid schizophrenia).Resident #114's most recent BIMS (Brief Interview of Mental Status) scored the Resident at 15/15 indicating no cognitive impairment. Resident #114's clinical record included a document entitled Provider Attestation for Schizophrenia/Schizoaffective/Schizophreniform Diagnosis that listed the medications for this diagnosis as Seroquel ER 150 mg per day, Depakote 500 mg 2 times daily and Haldol 10 mg 2 times daily. All meds read for diagnosis of Psychotic disorder with hallucinations due to a known physiological illness.On 7/16/25 the Administrator was asked for all reportable incidents involving Resident #114 during the time of his stay at the facility. The Administrator supplied 2 documents entitled Facility Reported Incident one was dated 8/10/24 and the other was dated 8/11/24. The Administrator was asked if this was all of them and she stated it was.A review of the clinical record revealed the following excerpts: 6/13/24 7:25 p.m. Resident was involved in a verbal/physical altercation with another resident in which Mr. V. [NAME] pushed [Resident name redacted] on her right shoulder, grabbed her right leg, stomped her glasses and kicked her phone in the grass. Writer questioned Resident about the incident, and he stated that she triggered him by saying what she said to him. 6-26-24 6:12 am. - On this date 06/12/2024 during my shift, resident was seen going out of the facility 0540, when asked where he was going, resident says what kind of question are you asking me, I want to get a cigarette lighter at nearby store. All effort to redirect him back to the facility was prove abortive until a staff followed him and drove him back to the facility. 6/29/24 5:16 - Resident was noted to be seen by staff at 0130. Staff went to resident room to check on him and he was nowhere to be found. Resident apparently had left the building unbeknownst to staff. Staff immediately did a sweep of the interior and exterior of the facility unable to locate Mr. [NAME]. Police were called and given a picture and description of the clothing the resident was wearing when last seen. Staff notified DON, RP and provider. Officers spoke with other officers in a different jurisdiction which stated they had him at [Convenience store name redacted] Staff was told by officers they would have to transport [Resident 114 name redacted] back to facility 6/29/24 5:58 a.m. - This writer saw resident at 0130 entered the dining room and later went to resident room to check on him and he was nowhere to be found. Resident had walk [sic] away from the building unknown to staff. Sweeping of the interior and exterior of the facility was done still unable to find [Resident #114 name redacted] Police were called and given a picture and description of the clothing the resident was wearing when last seen. DON was notified, RP and provider. Officers spoke with other officers in a different jurisdiction which stated they found him at [convenience store name redacted]. Staff was [sic] told by officers they would have to transport [Resident#114 name redacted] back to facility. Staff drove to the location where he was found (approximately 7.1 miles away from the facility) and bring [sic] him back to the facility. Head to toe Skin assessment was done and intact. Resident was later sent out to hospital for psych consult EMS notified and resident was transported to the hospital by 2 EMS at 0535. 7/2/24 9:30 a.m.- I was able to find legal Guardian's phone number. I called her to speak about resident's wander guard. She said that resident has a history of wandering, and she would really appreciate him having a wander guard. She asked if it had a tracking device, and I explained that it only alerted us when he went out the building. She said that it was fine and appreciated the call.On 7/16/25 at approximately 11:45 a.m. an interview was conducted with the Administrator; she was asked why the first 3 incidents of elopement were not reported to the OLC and other entities as required by regulations. The Administrator stated that Resident #114 had a High BIMS score and therefore he could leave the facility if he signed himself out. She stated that he did not sign himself out of the facility. The Administrator was asked if Resident #114 had Any conditions that would affect his decision-making ability, she stated that he had a diagnosis of Schizophrenia. On 7/17/25 an interview was conducted with Employee L who was asked if a Resident with a BIMS of 15 can leave the facility unescorted, Employee L stated that it would depend on the physical and mental state of the Resident. When asked if BIMS alone could determine the ability of a Resident to leave the facility unescorted and she stated the BIMS was only one piece of the equation. Employee L stated that the Resident must be safe to ambulate independently and able to make safe decisions and notify the facility when he or she is leaving the facility. She stated that the RP must also be aware of the residents leaving the facility. Employee L also stated that the LOA (Leave of Absence) form must be signed prior to leaving the facility.On 7/18/25 the Administrator was made aware of the concerns, and no further information was provided.

Based on resident interviews, staff interviews, and review of facility documents, the facility staff failed to protect a resident's right to be free of sexual abuse for 2 of 5 residents (Resident #1 and Resident #3) in the survey sample, which constituted harm. The findings included: Resident #1 was initially admitted to the facility on [DATE]. The current diagnoses included other mechanical complications of the internal right hip prosthesis, muscle weakness, chronic kidney disease, other sickle-cell disorders without crisis, anxiety disorder, and major depressive disorder. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 2/15/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated that Resident #1's cognitive abilities for daily decision-making were intact. Resident #3 was no longer a resident of the facility; therefore, a closed record review was conducted. Resident #3 was admitted to the facility on [DATE], was discharged home on 4/25/25. The resident's diagnoses included metabolic encephalopathy, unspecified cirrhosis of the liver, muscle wasting and atrophy, and end-stage renal disease. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/28/25 coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated that Resident #3's cognitive abilities for daily decision-making were intact. An interview was conducted on 5/6/25 at 4:55 PM with Resident #1. Resident #1 stated that in February 2025 (not sure of the exact date), the Receptionist said to him, You are too stressed out. You need your dick sucked. Resident #1 also stated that a few days later, the same Receptionist displayed a picture on his phone to Resident #1 of him giving oral sex to another male. Resident #1 further stated that he informed the Activities Assistant regarding these two occurrences. During the interview, Resident #1 stated that at the end of March 2025 (not sure of the exact date), the Receptionist puckered his lips up, blew a kiss, and made smacking sounds directed towards him. Resident #1 also stated, I felt humiliated and got angry. Resident #1 further stated that immediately after this incident occurred, he saw the Assistant Director of Nursing (ADON) in the hallway laughing and felt as if she was laughing at him. Resident #1 stated that he asked the ADON why she was laughing and said to her, Everyone knows what that faggot did to me. On 5/6/25 at 5:55 PM, during the interview, Resident #1 became very emotional and began crying. Resident #1 stated, I have not had the best life. I've seen a lot of things. It's been hard for me to get this out of my mind. Why did he target me? I'm someone that has health issues. He was trying to take advantage of me. I feel like people are laughing at me. Am I a video game? I'm not gay. It's about my dignity. It's embarrassing and humiliating, and I'm angry. An interview was conducted on 5/7/25 at 3:15 PM with Certified Nursing Assistant (CNA) #2. CNA #2 stated that on 3/29/25, a Transportation Driver approached him and stated that the receptionist was very inappropriate in a sexual manner with him. CNA #2 also stated that on this same day, the receptionist got very close to him as well and started making funny noises in his ear. CNA #2 further stated that he perceived the actions that the receptionist did were sexual and told the receptionist, I don't go that way. Don't even try it. CNA #2 lastly stated that he did not tell the management team about these occurrences until the following week on 4/2/25 when he was asked questions by the Director of Nursing (DON) regarding the receptionist. A review of a written statement dated 4/2/25 by the Transportation Driver read: On Saturday, March 29, 2025, I came to pick up a resident for dialysis. As I was walking to push the resident's wheelchair, the weekend ambassador stood in front of me and tried to grab my private area. I pushed his hand away. He tried to touch my private area again, so I left to get a witness. I grabbed a CNA, and he stopped trying to touch me. After that, I had no more incidents with him. An interview was conducted on 5/7/25 at 5:35 PM with the Administrator. The Administrator stated that a Facility Reported Incident was initiated and investigated regarding the incidents that occurred over the weekend of 3/29/25-3/30/25. The Administrator also stated that the police were contacted on 4/3/25 to inform them of the sexual allegations, and a police report was filed. The Administrator further stated that the Receptionist was terminated and is not registered with any licensing board. The Administrator lastly stated that sexual abuse was confirmed for four individuals (Resident #1, Resident #3, CNA #2, and the Transportation Driver), and the allegations of sexual abuse are substantiated. An interview was conducted on 5/8/25 at 12:20 PM with the former ADON. The former ADON stated that on 3/31/25, Resident #1 told her that the receptionist puckered his lips up, blew him a kiss, and made a smacking sound. The former ADON also stated, Resident #1 was very agitated, upset, and visibly irritated. An interview was conducted on 5/8/25 at 12:38 PM with the Discharge Planning Assistant. The Discharge Planning Assistant stated that she interviewed Resident #3 on 4/2/25 regarding interaction with the weekend receptionist. The Discharge Planning Assistant also stated that Resident #3 informed her that on one occasion the Receptionist came to his room to inform him that his ride was on the way and said to him, I want to suck that dick. The Discharge Planning Assistant further stated that Resident #3 said he was unsure if he heard him correctly. However, the Receptionist repeated it again as they got closer to the double doors. The Discharge Planning Assistant lastly stated that Resident #3 said when he came back to the facility from his dialysis appointment, the receptionist was standing in the business office with the lights off and was beckoning him to come in, however he ignored him. An interview was conducted on 5/8/25 at 2:10 PM with the Activities Assistant. The Activities Assistant stated that Resident #1 told her that the male receptionist said to him, have you ever had your dick sucked? The Activities Assistant also stated that Resident #1 said that the receptionist has videos of it on his phone. The Activities Assistant further stated, I'm a mandated reporter, so I told the Social Worker Assistant and the Social Worker about this, and then the Administrator wanted to speak with me. The Facility's Abuse/Neglect/Misappropriation/Crime policy with an effective date of 10/17/23 read: Patients of the Center have the legal right to be free from verbal, sexual, mental, and physical abuse, corporal punishment, involuntary seclusion including abuse facilitated or enabled through the use of technology, and free from chemical and physical restraints except in an emergency and/or as authorized in writing by a physician. On 5/8/25 at approximately 5:00 PM, a final interview was conducted with the Administrator, Director of Nursing, and Regional Director of Clinical Services. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on interviews, clinical record review, and facility documentation, the facility staff failed to ensure the Residents were free of accident hazards and provided adequate supervision for two (2) Residents (#3 and #4) in a survey sample of nine (9) Residents. This resulted in immediate jeopardy for Resident #3 and potential for harm for Resident #4. The findings included: 1. For Resident # 3, the facility staff failed to provide supervision while smoking outside of the building, allowing Resident #3 to leave the facility grounds unsupervised. Resident #3 was admitted to the facility on [DATE] with diagnoses that included but were not limited to generalized anxiety disorder, depression, unspecified intellectual disability, alcohol dependence with withdrawal, alcohol-induced persistent dementia, other symptoms and signs involving cognitive awareness, and respiratory conditions due to smoke inhalation. Resident #3's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/5/24, assessed by the facility Social Worker, scored Resident as a 5/15, indicating severe impairment in cognitive skills. On 9/4/24, a review of the smoking policy revealed the following information: Patients smoking in the designated smoking grounds area are to be supervised as deemed appropriate through their individual Safe Smoking Assessment. The Safe Smoking Assessment screening was reviewed on 5/27/24 and 8/27/24. Resident #3 received scores of 2 and 0. According to the key, a score of 0-4 is considered safe to smoke unsupervised. [Please note that the smoking assessment screens explicitly for the ability to light and handle smoking materials physically.] A review of the elopement assessments revealed that on 2/14/24, Resident #3 scored a 10; on 5/14/24, again, a 10; and on 8/14/24, 11 was scored, all three indicating a high risk of elopement. On 9/4/24 at approximately 1:00 p.m., Resident #3 was noted to be outside the building smoking with other residents, and she returned to the building after she finished smoking. On 9/4/24, at approximately 2:00 p.m., Resident #3 was interviewed. She said she never left the building unsupervised or went to the store. She stated that the staff always opened the door for her to smoke outside. She denied ever wandering off or going to buy beer at a store. At this point, Resident #3 ended the interview by walking away. On 9/4/24, at approximately 11:00 a.m., the receptionist was observed bypassing the wander guard alarm for another resident to go outside to smoke. When asked what the sound was, she stated it was the wander guard alarm. When asked if she bypassed it by putting in the code, she said she did. When asked why, she stated that the Resident was a smoker and allowed to go and smoke. A review of the clinical record on 9/4/24 revealed that Resident #3 had eloped from the facility grounds on several occasions since May 23, 2024. The following excerpts are from the clinical record regarding Resident #3's elopement: 5/23/24 1:39 p.m. -Writer contacted by nurse that resident was seen near road at entrance of facility when nurse tried to redirect resident walked back towards back of facility. Writer traveled to back of building where resident was located. Resident stated that she was just walking around. Writer explained to resident that it is not safe to walk around outside the facility without a staff escort. Resident stated she was trying to exercise. RP was made aware. 6/12/24 2:03 p.m. - Code orange called at 1250 pm as patient was seen walking off the premises. Patient was able to be redirected inside the building when asked why she left patient stated she no longer wanted to live here, she is bored and has nothing to do. 6/14/24 6:09 p.m. - She eventually put out the cigarette but continuously kept trying to walk off the facility premises. Twice she was redirected back while she agitated and using profane words at staff. She refused all her medications. RP notified. 7/18/24 10:18 a.m. - Left facility unsupervised to go to the store. Resident found at the store purchasing Alcohol. 7/28/24 8:39 p.m. - [Resident name redacted] was seen by staff at approximately 6:00 pm. A fell ow resident who had walked to the store stated she was at the store with him but when he turned around, she was gone. The supervisor called a code orange, notified the police, called the RP, notified the DON and the administrator. Within 10 minutes she was located by her RP. Police were notified that she was found safe and was with a relative. The administrator and DON were also notified. The RP stated she would keep her for an hour or so to calm her down and then return her to the facility. Upon her return resident was still noted to be agitated and still continued to leave the premises. She attempted to hit staff and was physically aggressive with her aunt. Resident will be seen by psych services this week. MD notified. Skin assessment completed no injuries. 8/1/24 3:51 p.m. - Spoke with [Responsible party name redacted] to make her aware that [Resident #3 name redacted] left the property and was at the [NAME] store and the cashier explained to staff that [Resident name redacted] is banned from their property. 8/2/24 7:30 p.m. - Resident has been leaving facility property since 2130 [sic]. Care staff was able to redirect resident back into facility. Resident then later insisted on going to the nearby store for something she wanted, and she wasn't coming back into the facility until she was ready. Resident was assisted back to facility by another staff member where she remains in her room on the phone at the time of this writing. 8/2/24 8:36 p.m. - Type of Behavior: Elopement Non-pharmacological Intervention: Talked and walked around the parking lot w/ her for a few minutes until she was ready to go back inside. 8/2/24 9:11 p.m. - Writer noticed resident walking by with alcohol in a bag going to her room. Writer attempted to ask resident to see what she had but she refused. 8/2/24 9:35 p.m. - Resident has left facility grounds unattended. 8/2/24 9:52 p.m. - Resident returned back to facility at 7:45 pm accompanied by writer 8/4/24 5:27 p.m. - Resident was reported to have left the facility unattended. Writer went outside in search of resident and CNA followed in her car. Resident was found at the [name of store redacted] store and she stated she was getting a drink but had no money. When advised to get in the car so she could return to the facility, she refused, crossed the street and kept walking towards the direction of the highway. Another nurse [nurse's name redacted] was informed at the facility to contact resident's RP while writer kept following Resident down the street, advising her to return. Resident eventually turned around, and her RP picked her up mid-way back to the facility. 8/23/24 6:56 p.m. - Resident was noticed to have left the facility around 1730 [5:30 p.m.]. A code orange was called but resident could not be found in or around the building. She could not be found at the [NAME] gas station. RP and DON were notified. Resident was found coming back from the direction leading to the 7-11. She was encouraged by writer and RP who had driven to the facility to assist in finding resident to return back to the facility. Resident walked back to building with writer. Immediate Jeopardy (IJ) was identified and verified after consultation with the state Licensure and Certification supervisory Staff on 9/5/24 at 12:47 p.m. The facility Administrator and Director of Nursing (DON) were made aware of IJ on 9/5/24 at 12:50 p.m. On 9/6/24 at 2 p.m., the facility submitted approved IJ Removal Plan: a) Immediate Supervision: As of 9/5/24 at 1:35 p.m., resident #3 is now under 1:1 supervision 24/7 to prevent elopement. As of 9/5/24, a dedicated staff member has been assigned to always monitor during smoke breaks. b) Wander Guard System: On 9/5/2024 at 1:35 p.m., the Resident #3 wander guard bracelet was assessed and functioning well. On 9/5/2024, the maintenance team re-evaluated and recalibrated the facility's wander guard system to ensure it functions correctly. All in-place wander guards have been checked and are working successfully. As of 9/5/2024, the facility has initiated training for all its staff on the importance of not passing the wander guard system and the potential consequences of doing so. c) Environmental Modifications: The front door will remain locked, and staff will continue to monitor exit doors, especially during high-risk periods when Resident #3 is likely to attempt to leave (e.g., smoking times). d) Smoking: As of 9/5/2024, Resident #3 will continue not to be allowed to smoke unsupervised. A designated smoking area has been established within a secure part of the facility, and staff will escort Resident #3 to and from this area. e) Staff Education and Training: On 9/5/2024, all staff will undergo immediate re-education on elopement risks, supervision requirements, and the specific needs of residents with cognitive impairments. Training sessions have been initiated to reinforce the importance of adhering to safety protocols and using the wander guard system. The plan is for all staff to report for oncoming shifts; they will not work until all re-education is complete. f) Resident Care Plan Review: On 9/5/2024 at 1:35 p.m., Resident #3's care plan was reviewed and updated to include specific interventions to prevent elopement. The care plan now includes detailed instructions for staff on supervising Resident#3 during all activities, including smoke breaks. The facility alleges compliance as of 9/6/24 at 1:00 p.m. Long Term Actions: i.) Ongoing Monitoring Regular audits will ensure compliance with the updated supervision protocols. While the patient remains in the facility, Resident #3's care plan will be reviewed monthly to assess the effectiveness of the interventions and make necessary adjustments. ii.) Family and Resident Involvement: As of 9/5/2024 at 1:50 p.m., Resident #3 and her family have been informed of the situation and steps to ensure her safety. Regular meetings will be held with the family to discuss concerns and provide updates on Resident #3's status. iii.) Policy Review and update: As of 9/5/2024, the facility's elopement policy has been reviewed and updated to reflect the new measures. All staff have received a copy of the updated policy and must acknowledge their understanding and commitment to following it. iv.) Quality Assurance As of 9/5/2024, a QA committee has been established to oversee the implementation of the abatement plan and ensure ongoing compliance. The QA committee will meet bi-weekly to review incident reports, monitor the effectiveness of interventions, and recommend further improvements as needed. The Survey Team verified that the following components of the Removal plan had been fully implemented on 9/6/24: The survey team reviewed the education provided and interviewed the staff on duty to ensure they had been trained and understood the content. The staff were questioned about Resident #3's supervision during smoke breaks and when she was out of the facility. The survey team reviewed the policy to ensure the updates included supervision while smoking in the designated smoke area. A review of the clinical record revealed that the facility staff updated the care plan to include, due to the resident's cognitive status, the need for supervision at all times while smoking. The facility staff documented contacting the Resident's Responsible Party and working together to find a facility with a more appropriate setting to provide enhanced security for the Resident. On 9/5/24, at approximately 2:00 p.m. (after the facility was informed of the immediate jeopardy), staff members were observed walking in the hallway with Resident #3. On 9/6/24, at approximately 9:00 a.m., Resident #3 was observed to have one-to-one (1:1) supervision outside in a sanctioned area during a smoke break. On 9/6/24 at 10:30 AM, the resident was also observed during a structured activity with 1:1 supervision. On 9/6/24 at 3:00 p.m., the survey team informed the Administrator that the IJ was removed based on validation of their removal plan and the scope and severity of the deficiency was lowered to a level 2, isolated. 2. For Resident #4, the facility staff failed to ensure the maintenance person had removed all tools from the roof after repairs, causing a hammer to fall on Resident #4's head, resulting in an evaluation in the emergency room . Resident #4 was admitted to the facility on [DATE]. Diagnoses for Resident #4 included but were not limited to pulmonary embolism, type 2 diabetes, acute kidney failure, seizure, substance abuse, hypertension, pancreatic cancer, and emphysema. Resident #4's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 7/16/24 coded Resident #4 with a BIMS (Brief Interview of Mental Status) score of 13/15 indicating no cognitive impairment. Minimum Data Set Coded Resident #4 as #1- supervision from staff for Activities of Daily Living care. On 9/5/24, a review of the clinical record revealed the following notes: 8/24/24 3:08 p.m.- On the day of Aug. 24, 2024, resident was involved in incident where nursing staff felt an assessment from E.R. should be required. [Resident #4 name redacted] at one point began to refuse to go to ER to be evaluated because he was afraid of losing room placement. We assured him that admission would follow up with him and he would be notified before any changes would occur. Resident later after strong encouragement from staff decided to go to E.R. to be evaluated. 8/25/24 1:30 p.m. -LATE ENTRY -Situation: Date and time the fall occurred: 08/24/2024 1:21 PM Background: Circumstances of the fall: Resident's cane was placed on roof of building, resident attempted to retrieve his cane from roof, and was hit in the head by object off roof. Assessment (RN)/Appearance (LPN): Current status of the resident's injuries or reports of pain from the fall: Resident has area to top of scalp, dry and intact Resident c/o pain 5/10 Recommendation: Interventions currently in place to prevent additional falls: Resident educated to ask for assistance resident's response to new interventions: Resident compliant. On 9/5/24, a clinical record review revealed that Resident #4 went to theER on [DATE] and was evaluated and released. There were no new orders; CT imaging of the head and neck was done to confirm no acute fractures or serious injury from the incident. The following excerpt was from the physician's notes. 9/2/24 1:00 p.m. -Patient discussed that he has been recovering and attempting to feel better physically. He reports a hammer fell off the roof the building when he attempted to retrieve his cane from the roof. Patient said it was hanging off the side of the building and a hammer fell and hit him on the head. Patient then reports he did not recall a lot of things. Patient said he was medically cleared at a hospital and has been following doctor's order. 9/5/24 at approximately 12:00 p.m. an interview was conducted with Resident #4 who stated he is feeling much better and still did not know how his cane came to be hanging off the side of the roof. He stated that he reached for it and then it must have knocked the hammer off when it came down on his head. He stated that he went to the emergency room , and they did some tests and x-rays and sent him back to the facility. When asked if he felt fearful or unsafe at the facility, he stated that he did not. He stated it was a 'Crazy accident.' On 9/5/24 at approximately 3:00 p.m. an interview was conducted with the Administrator who stated that the incident did happen an investigation was done, and the maintenance person was educated on ensuring tools were not left where they could injure residents. On 9/5/24 during the end of day meeting the Administrator was made aware of the concerns and no further information as provided.

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to implement their abuse policy affecting 2 residents (#53 and #85), resulting in harm for Resident #53. Immediate Jeopardy (IJ) was identified on 09/27/2023 at 5:25 p.m., at which time the facility Administrator and Director of Nursing were made aware. Following verification of the removal of immediacy, the facility abated IJ on 10/04/2023 at 10:45 a.m. The scope and severity was lowered to a level 3, pattern. The findings included: 1. The facility staff failed to implement their abuse policy by permitting facility staff to work when their criminal background status was unknown. On 09/27/2023, a review was conducted of a sample of employee files which revealed the following: a. Staff #4 was hired 03/17/2022 and terminated employment on 10/01/2022. Staff #4's employee record had no evidence that a criminal background check had been obtained. Therefore, from 03/17/2022 - 10/01/2022, facility staff were unaware of Staff #4's criminal background status, and the staff member provided direct resident care during this time. b. Staff #10 was hired on 10/31/2022 and terminated employment on 01/10/2023. There was no evidence provided to indicate that Staff #3 had a criminal background check performed. Therefore, from 10/31/2022 - 01/10/2023, facility staff were unaware of Staff #10's criminal background status and was permitted to provide direct care to residents. c. Staff #13 was hired 07/5/2022 and terminated employment on 10/08/2022. Staff #13's employee record had no evidence of a criminal background check on file. Therefore, from 07/05/2022 - 10/08/2022, facility staff were unaware of Staff #13's criminal background status and was permitted to provide direct care to residents. d. Staff #24 was hired 03/08/2023. Staff #24's criminal background check was requested on 03/07/2023 and noted to read, Transaction is being processed and the final report was not on file. Therefore, from 03/08/2023 until the time of survey, the facility staff were unaware of Staff #24's criminal background status and the employee was permitted to continue to work without knowing if the employee was guilty of a barrier crime. On 09/27/2023 at approximately 1:00 p.m., an interview was conducted with the Human Resources Director (HRD) who stated, We get criminal background checks on every applicant. For the Virginia State Police, we wait 30 days, and they can work with another employee while we wait for it. The HRD verified that Staff #4, #10, #13, and #24 did not have a criminal background report within 30 days of their respective hire dates. A review of the facility's policy entitled, Abuse/Neglect/Misappropriation/Crime Prevention/Screening/Training, dated 01/23/2020, subtitle, Procedure, item 1 read, Criminal background and reference checks are performed on all employees. Prior to conclusion of the survey, the facility staff provided the survey team with a facility policy entitled, Onboarding/Virginia, with an effective date of 10/01/2023, which was reviewed. This policy read, The company will comply with all local and state regulations and guidelines as required for all employees who are employed in the Commonwealth of Virginia. 1. A complete and accurate personnel file, as outlined in Policy #207 and in accordance with 12VAC5-371-140-E of the Administrative Code of Virginia, will be created for each new employee which contains the basic demographic and indicative data needed for employment, as well as: a. A criminal history check of the Central Criminal Records Exchange conducted via Virginia State Police Non-Criminal Justice Interface (NCJI) in accordance with 32.1-126.01 of the Code of Virginia . 2. For Resident #53, the facility staff failed to prevent the resident from being abused by a staff member. After being made aware of the allegation, the facility staff failed to take measures to protect the Resident #53 from their alleged perpetrator, which permitted the staff member to abuse the resident again. On 09/26/2023, during a clinical record review of Resident #53's clinical chart, the following was noted: a. Resident #53 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. b. A progress note dated 08/10/2023 at 5:06 p.m. stated, Patient sent to Saint Mary's for evaluation r/t [related to] alleged assault, MD [medical doctor] made aware. Patient verbalized understanding the reason for transfer. c. Another progress note dated 08/10/2023 at 5:15 p.m. read, Patient made a statement in regard to an assault that took place this morning, a statement was given from patient to myself dictated at 2:11 PM at the south unit nursing station. Phone call placed to nonemergency services so patient could give an official statement and press charges. On 09/27/2023, a review was conducted of the facility's documentation regarding the events involving Resident #53. There was a written statement taken from Resident #53 that read, Statement of [Resident #53's name redacted] patient stated that while he was asleep, he was awakened by a washcloth being placed on his face, he then heard a voice say, can you see me? Patient then says in return, I am not blind. Patient states the CNA [certified nursing assistant/CNA C] then pulled off his sheets and undid his brief and began flicking his penis back and forth. Patient states the CNA then stated he was going to shave his pubic hairs. Patient stated he began to yell out for help, which caused the CNA to abruptly stop, then pick the patient up and throw him in the chair. Patient then restated all of the above details to the speech therapist. On 09/27/2023 at 11:26 a.m., an interview was conducted with the facility Director of Nursing (DON), with the Administrator and survey team present. The DON was asked about the incident involving Resident #53 and CNA C. The DON reported, On 8/10 when I came in the speech therapist (SLP) came and talked with me 8:30 a.m., and gave me a service concern and said she saw Resident #53 and he reported that a CNA had touched him inappropriately. I went and talked with him [Resident #53] and he said when he did foley care it was discomfort. Then at noon he said the CNA had put a washcloth over his face and he was flicking his penis back and forth. He could not give a name or describe the person, we had one male CNA working that day, she identified as [CNA C's name redacted]. I asked him [Resident #53] if he wanted to be sent out, he said yes. The DON stated she had CNA C sent home prior to her arrival at the facility early that morning due to performance issues, prior to her knowledge of the allegation involving Resident #53. However, it was later determined that CNA C had not been removed from the premises until over 5 hours following the initial incident. On 09/27/2023 at 12:10 p.m., an interview was conducted with Employee M, the Speech Language Pathologist (SLP). The SLP reported on 08/10/2023, she arrived to work at 7:50 a.m., and as she walked down the hall, Resident #53 got her attention and reported, the aide [CNA C] had put a washcloth on his face and he had touched his penis. I told the nurse. The SLP stated at about 9:30 a.m. in the dining room, she saw Resident #53 being fed by the CNA who had allegedly abused the resident earlier that morning. The SLP said, I saw his [Resident #53] mouth was stuffed full of food, and I saw that was way too much and he [CNA C] was getting ready to put more in his mouth. I had the Resident spit it out and said that's why too much and it was the wrong diet texture, he [CNA C] said that's what they sent. I had to take over feeding the Resident. The SLP reported that she reported this incident to nursing leadership and her immediate supervisor. Later that day, she saw CNA C still in the facility/in passing in the hall. She was not sure of the time. The SLP said she reported the events to the Director of Nursing and wrote a statement regarding the events involving Resident #53 and CNA C. On 9/27/23, Surveyors D and F attempted to interview Resident #53, but the resident was not available for interview. On 09/28/2023 at 3:00 p.m., Surveyors D and F visited Resident #53 in his room. Resident #53 gave the same accounting of events that were in the written statement referenced earlier. There was no change in his report. The resident became very tearful and stated he was so afraid and that CNA C laid me flat in the chair on my back and was trying to silence me and say I choked on food. Resident #53 said, [Employee M's name redacted] took a picture. The resident stated that following this incident he was afraid to sleep, kept looking around, and had to be prescribed Trazadone so he could sleep. When asked how all of this made him feel, Resident #53 said, Like I wanted to leave here, I was scared, I can't move, I was afraid I was going to choke, he was trying to silence me so he could say I choked. I watched all the time. This was harm. An additional review of the clinical record revealed that Resident #53 was ordered Trazodone 50 mg tablet to be given at bedtime for sleep aid on 08/23/2023. On the afternoon of 09/29/2023, an interview was conducted with the scheduler, who stated on the afternoon of 08/10/2023, she was told by the Director of Nursing to send CNA C home, due to complaints and work performance. Review of payroll records revealed that CNA C did not clock out and leave the premises on 08/10/2023 until 1:17 p.m. A review was conducted of the facility's abuse policy titled, Abuse/Neglect/Misappropriation/Crime/Administrative Reference Guide. Excerpts from this policy read, 1. Physical abuse: b. physical contact intentionally or through recklessness that results in, or is likely to result in, death, physical injury, pain, or psychological harm to the patient. Indications of psychological harm include a noticeable level of fear, anxiety, agitation, or emotional distress in the patient. 3. Sexual Abuse: a. sexual harassment, inappropriate touching. The policy titled, Abuse/Neglect/Misappropriation/Crime/ Patient Protection, was reviewed. This policy read, There is a zero tolerance for mistreatment, abuse, neglect, misappropriation of property, or any crime against a patient of the Health and Rehabilitation Center. 1. Patients of the center have the legal right to be free from verbal, sexual, mental, and physical abuse, corporal punishment. 2. Any employee and/or covered agent of the Center, who willfully abuses . or participates in any criminal activity against any patient of the center will be immediately subjected to corrective action. 3. For Resident #53, the facility staff failed to report and investigate allegations of abuse. On 09/27/2023, a review was conducted of the facility's documentation of the allegation and actions taken regarding Resident #53 and the incidents with CNA C. There was a written statement taken from Resident #53. There was also a written statement from Employee M, the Speech Language Pathologist (SLP). Lastly there was evidence the state survey agency/Office of Licensure and Certification (OLC) and Adult Protective Services (APS) were faxed a report of the incident on 08/10/2023 at 7:10 p.m. There was no evidence that an investigation into the allegations was conducted. The report submitted to the OLC and APS lacked significant information regarding Resident #53's allegations involving CNA C. The details of being awakened by a washcloth being put across his face, saying he was going to shave the resident's pubic hair, and the details of the aggressive feeding were all omitted from the report. On 09/27/2023 at 11:26 a.m., an interview was conducted with the facility's Director of Nursing (DON), with the Administrator and survey team present. The DON was asked about the incident involving Resident #53 and CNA C. The DON reported, On 8/10 when I came in the speech therapist (SLP) came and talked with me 8:30 a.m. and gave me a service concern and said she saw Resident #53 and he reported that a CNA had touched him inappropriately. I went and talked with him [Resident #53] and he said when he did foley care it was discomfort. Then at noon he said the CNA had put a washcloth over his face and he was flicking his penis back and forth. He could not give a name or describe the person, we had one male CNA working that day, which she identified as [CNA C's name redacted]. I asked him [Resident #53] if he wanted to be sent out, he said yes. The DON stated that she had CNA C sent home prior to her arrival at the facility early that morning due to performance issues, prior to her knowledge of the allegation involving Resident #53. During the above interview, the DON was asked to explain what steps were taken to investigate the allegation and if she had any additional documentation regarding an investigation. The DON stated she had interviewed other residents and reviewed the hospital records of Resident #53. Because there was no forensic evidence, she unsubstantiated the allegation. The DON was asked to provide evidence of the resident interviews she conducted, and she said she had nothing to provide. When asked if staff, including but not limited to CNA C, were interviewed, the DON indicated none of the staff were interviewed. The facility had no evidence of any investigation being conducted. A review was conducted of the facility's abuse policy titled, Abuse/Neglect/Misappropriation/Crime/Reporting Requirements/Investigations. Excerpts from this policy read, 2. The Administrator and/or Director of Nursing will immediately initiate a thorough internal investigation of the alleged/suspected occurrence. The investigation protocol will include, but not be limited to, collecting evidence, interviewing alleged victims and witnesses, and involving other appropriate individuals, agents, or authorities to assist in the process and determinations. Immediate Jeopardy (IJ) was identified on 09/27/2023 at 5:25 p.m., at which time the facility's Administrator and Director of Nursing were made aware. On 10/02/2023 at 3:30 p.m., the facility submitted an accepted IJ removal plan and on 10/04/2023, submitted a revised plan which read as follows: 1. 9/27/23: Resident #103 reported an allegation of abuse on 8/10/2023 and FRI submitted regarding resident #85. 2. 9/27/23: FRI submitted for an allegation of abuse on 8/10/2023 involving resident #53 and #85. Physician, responsible party, and police notified, and case assigned to detective [NAME]. 3. The identified CNA, [Name redacted], removed from schedule on 8/10/2023 and no longer permitted in the center. 4. 9/28/2023: [Name redacted] license (CNA) reported to the board of nursing. 5. 9/28/2023: Facility personnel educated on the abuse policy to identify, protect, report, and investigate allegations of abuse prior to working. 6. 9/27/2023: New hires educated on abuse policy prior to working. 7. 9/27/2023: Regional Director of Human Resources reviewed all personnel files to verify Virginia State Police (VSP) background checks. 8. 10/2/2023: Employees with pending VSP background check clearances removed from the schedule. 9. 9/27/2023: Regional Human Resources educated Administrator and managers on screening employees and VSP background checks clearance. 10. 9/27/2023: The facility educated all personnel on protecting, reporting, investigation, screening employees, and adhering to a mandated reporting procedure. 11. 9/27/2023: The facility interviewed residents to determine if there was any other allegation of abuse. 12. 9/27/2023: skin checks completed on residents who could not be interviewed to determine any signs of abuse. 13. 9/27/2023: The facility completed a comprehensive audit of all FRIs and service concerns that occurred from January 2023 up to the present to ensure no other case of abuse existed. 14. 9/27/2023: The facility identified an allegation of abuse involving a receptionist, and resident #103. 15. Receptionist suspended pending an investigation. A FRI sent to the Office of Licensure and Certification on 9/26/2023. 16. The implementation deadline of this immediacy removal plan is October 2, 2023, by 3:20 PM. On 10/02/2023, the facility's administration submitted to the survey team credible evidence of the IJ immediacy removal plan. Included in the documents was documentation of Direct Supervision, which indicated that employees without a criminal background check clearance would be permitted to work under the direct supervision of a staff member with a criminal background clearance. The survey team notified the facility's administration that this was not permissible, and that each employee had to have a criminal background check clearance to work beyond 30 days of employment. On 10/03/2023, the survey team attempted again to verify the facility staff had implemented their approved IJ immediacy removal plan. Staff interviews were conducted with facility staff from various departments to ensure they were aware of what abuse is, how to respond and protect residents in the event of abuse, and that they were mandated reporters. The survey team obtained a resident census listing and cross checked to ensure that residents who could be interviewed had been interviewed, and residents who could not be interviewed had a head-to-toe assessment. There was one resident identified that had not been interviewed or assessed for signs of abuse. The survey team reviewed the employee audits and identified that the contracted dietary, housekeeping, and laundry staff had not been audited to ensure they had a criminal background check from the Virginia State Police that indicated they were free from any barrier crimes. On 10/03/23 at 4:40 p.m., the facility Administrator and corporate staff were made aware that the survey team had been unable to verify abatement. On 10/04/2023, the survey team returned to the facility for them to attempt to abate IJ. The facility staff provided the survey team with a head-to-toe assessment for the resident that had previously not been assessed for signs and symptoms of abuse. Additionally, the team reviewed the employee record audit and noted that the contracted staff were now listed. However, the audit indicated that Staff #24, who was a cook, was noted as having had a criminal background check. It had previously been noted as recently as 10/03/2023, Staff #24 did not have a criminal background check on-file at the facility and his status regarding barrier crimes and his criminal record remained unknown. In addition, 2 agency staff members were noted on the current working schedule for the day and there was not any evidence provided to indicate they had been screened for criminal records. On 10/04/2023 at approximately 10:00 a.m., the facility's Administrator was again made aware that they were unable to abate IJ. On 10/04/2023 at 10:40 a.m., the facility's Administrator returned with a revised audit which correctly reflected that Staff #24 did not have a criminal record on file. The audit verified that employees without a criminal background check had been removed from the schedule and were not currently working. The facility's administration also provided a criminal background that was free from barrier crimes for the 2 agency staff working. The survey team confirmed IJ was abated on 10/04/2023 at 10:45 a.m. 40026 4. For Resident #85, the facility staff failed to implement the abuse policy by reporting an allegation of sexual abuse. On or about 08/10/2023, an allegation that a CNA shaved the pubic hair of Resident #85, who is cognitively impaired and unable to be interviewed. The allegation was reported by the CNA who cares for her and the roommate of Resident #85. On 09/26/2023, an interview was conducted with Resident #103, who stated she knew that Resident #85 had been molested by a male CNA. She allowed the surveyors to listen to an audio recording of CNA E questioning Resident #85. According to the audio recording, CNA E could be heard saying, Why did you let that man shave you down there. Resident #85 has a Brief Interview of Mental Status (BIMS) score of 99, and stated she did not let anyone shave her to which you can hear the CNA reply, You are mighty bald down there. You got less hair than me and I was waxed. On 09/27/2023 at 1:00 p.m., an interview was conducted with CNA E who admitted that she had knowledge of the incident and that she made the nurse and the former DON aware of the incident; however, she did not report it as abuse at that time. On 09/26/2023, an interview was conducted with the DON, who was asked if she reported the allegation of sexual abuse, and she stated that she did not find it was abuse. She stated she heard about it from Resident #103, and she did not consider it abuse. The DON stated, Coming from (Resident #103 name redacted) I don't believe it. When asked again if she followed the abuse policy, and reported to the appropriate parties, she stated she did not think it was abuse so she did not report it. A review of the Abuse Policy read: All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. On 10/04/2023 during the end of day meeting, the Administrator was made aware of the findings. No further information was provided.

Based on resident interview, staff interview, and facility documentation review, the facility failed to ensure 5 of 5 nursing staff members (Staff #6, Staff #21, Staff #22, Certified Nursing Assistant [CNA]-H and CNA-K) in the sample were competent to provide care to the facility's resident population, resulting in psychological harm for Resident #22. Findings included: The facility staff failed to ensure nursing staff had the competencies including knowledge, skills, and abilities, necessary to meet the resident's needs when diagnosed with trauma/Post-traumatic Stress Disorder (PTSD) in accordance with the facility assessment, resulting in expression of psychological harm for Resident #22. During the initial tour of the facility on 09/25/2023 at 11:50 a.m., Resident #22 approached the surveyors (Surveyor C and Surveyor D) and stated he had PTSD, and the facility staff did not know how to take care of people diagnosed with PTSD. Resident #22 stated he was upset about it. He stated he really was diagnosed with PTSD. They (facility staff) act like they don't know how to handle it (PTSD). Resident #22 stated the staff treated him as if he was pretending. Resident #22 stated this is serious. The resident stated he did not feel understood by the staff. Resident #22 discussed his feelings more in depth with Surveyor D during the survey. On 09/26/2023 at 9:05 a.m., an interview was conducted with Licensed Practical Nurse B who stated there were residents in the facility who had diagnoses of PTSD and other behavioral health conditions. LPN-B stated she had not received specialized training on caring for residents with trauma/PTSD. On 09/27/2023 at 12:55 p.m., an interview was conducted with Certified Nursing Assistant-L who stated she had not received any special training on caring for residents with trauma/PTSD. Review of the Facility Assessment revealed a review date of 08/31/2023. The facility assessment, Part 2. Services and Care Offered Based on Resident Needs (on page 1 of 2) Section 2.1 General Care and Specific Care or Practices listed the general care area of Mental Health and Behavior and under Specific Care or Practices was written, Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with .trauma/PTSD, other psychiatric diagnoses . On 09/27/2023 at 2:15 p.m., an interview was conducted with the Staff Development Coordinator who stated she provided in-service education and training to the facility staff members. The Staff Development Coordinator stated staff members also complete computer-based training on required subjects. She stated she was aware the facility accepted residents for admission who were diagnosed with behavioral health issues to include but not limited to mental, psychosocial, or substance use disorder, a history of trauma and/or post-traumatic stress disorder, or other behavioral health condition and dementia according to the facility assessment. The Staff Development Coordinator stated the facility assessment was utilized to ensure residents could receive the care and services necessary for their well-being. The Staff Development Coordinator stated she was not told to include trauma/PTSD in the training topics but would immediately begin to train on that topic. Review of the 5 sampled employee training records revealed no documentation of training on trauma/PTSD. All 5 staff members were hired in 2022 or 2023 (Staff #6 LPN hired in 2023, Staff #21 hired in 2022, Staff #22 hired in 2022, CNA-H hired in 2023 and CNA-K hired in 2022). During the end of day debriefing on 09/27/2023, the facility Administrator, Director of Nursing, and Corporate Nurse Consultant were informed of the findings of no behavioral health training on trauma/PTSD. They were informed that none of its staff members had received any training/education or met competencies regarding the provision of care to residents diagnosed with trauma/PTSD. The residents' needs were not being met in order for them to reach their highest potential. On 09/28/2023, the Staff Development Coordinator provided a copy of the training curriculum including topics covered during orientation and training sessions. Review of the curriculum revealed there was no documentation of the topic of trauma/PTSD (Post-traumatic Stress Disorder. During the end of day debriefing on 10/03/2023, the facility Administrator, Director of Nursing, Corporate Nurse Consultant, and [NAME] President of Operations were informed of the findings. They were informed by Surveyor D that one resident expressed feelings of psychosocial harm. No further information was provided.

Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to ensure residents who display or are diagnosed with mental disorder, or history of Post-traumatic Stress Disorder (PTSD) receives appropriate treatment and services to attain the highest practical mental and psychosocial well-being for 1 resident (Resident #53) in a survey sample of 48 residents. The findings included: For Resident #53, the facility staff failed to ensure the resident received appropriate services post sexual assault by a staff member at the facility. Resident #53 was admitted to the facility on [DATE] with diagnoses that include but are not limited to schizoaffective disorder, hemiplegia after CVA (Cerebrovascular Accident or stroke) right sided, HIV (Human Immunodeficiency Virus), Hepatitis C, and Hypertension. A review of the clinical record revealed the following: 8/10/2023 5:06 pm Transfer to Hospital Summary Note Text: Patient sent to [hospital Name redacted] for evaluation r/t alleged assault, MD made aware. Patient verbalized understanding the reason for transfer. 8/10/2023 - 5:15 pm Health Status Note Text: Patient made a statement in regard to an assault that took place this morning, a statement was given from patient to myself dictated at 2:11 pm at the south unit nursing station. Phone call placed to nonemergent services so patient could give an official statement and press charges. 8/12/2023 4:51 -Alert Note Text: Due to safety concerns r/t behavioral issues; constant yelling and threatening staff to throw himself out of the bed when in room/bed. Administration made aware to possibly consider moving room closer to nurses' station. 8/15/2023 2:41 pm COMMUNICATION - with Resident Note Text: [name redacted] and [name redacted] spoke with [Resident #53] about his feelings today 8/15/23. Therapy reported that [Resident #53] wants to harm self, to which [Resident #53] admitted . [Resident #53] says that he can come up with a plan to harm himself [name redacted] made Dr. [name redacted] (psych) aware. 8/17/2023- 5:50 AM -Health Status Note-Note Text: Per reports, resident was suicidal during the day shift. Hourly checks done on resident throughout the shift, resident stated he had no plan or intention to commit suicide. During multiple encounter, resident was noted to be impatient, combative towards staff such as throwing water at care staff or yelling for not providing him with his needs as soon as he asked for them. Nurse provided education that he needs to give staff time to respond, also he needs to communicate with his words rather than violently/physically attempting to hit staff. Incontinent care provided every 2 hours and as needed, fall precautions followed and maintained, he is stable and resting in bed at this time. On 09/27/2023, an interview was conducted with the DON who was asked if they have psych services in the building and she stated they did. When asked if she thought it would be beneficial for Resident #53 to have seen psych services after such an incident, she stated she thought he did and would supply the notes from psych services. A review of the clinical record revealed that Resident #53 had an order dated 08/01/2023 that read Psych Consult as needed; however, the resident was not seen by psych services until 08/23/2023. The visit on 08/23/2023 was not prompted by the sexual assault. A review of the psych notes revealed the following: Resident was referred today for stabilization in depressed mood. Per nurses' notes and report, resident is reported to be verbally abusive to staff, and refusing care sometimes, Resident was met in his room, in bed, calm, alert, speech clear and engaged. Resident reported in on multiple psychotropic medications to include Lithium, Haldol, Risperidone, Diazepam, Ativan, Methadone, Seroquel, Hydroxyzine and Trazadone. Reported he has not been sleeping well a night. I stay awake the whole night; I cannot sleep. Resident also reported he feels sad and depressed. On 08/23/2023 after the psych visit, the order was given for Trazadone 50mg for insomnia. On 09/28/2023 at approximately 3:00 p.m., Resident #53 was interviewed about the incident on 08/10/2023 involving the sexual assault by CNA C. Resident #53 stated that he was afraid to have male staff anymore. He stated he was unable to sleep at all after the incident and was prescribed Trazadone as a result. Resident #53 was in tears when explaining how the incident made him feel helpless and fearful because he has contractures that prevent him from defending himself. Resident #53 stated he was aware the CNA would no longer be in the building but still did not want any male CNA staff to work with him. When asked if he was provided with emotional support or psych services immediately following the incident, he stated that he did not. On 10/04/2023 during the end of day meeting, the Administrator was made aware of the concerns. No further information was provided.

Based on resident interview, staff interview, and facility documentation review, the facility staff failed to update the facility assessment to assess the needs of its resident population, the required resources to provide the care and services the residents need resulting in expression of psychological harm by one resident (Resident #22) in the survey sample of 46 residents. Findings included: The facility failed to develop and implement a plan to provide care and services to include education, training, and competencies related to the care of residents diagnosed with Post-traumatic Stress Disorder (PTSD) resulting in one resident (Resident # 22) expressing psychological harm. On 09/25/2023 at 11:50 a.m. during the initial tour of the facility, Resident #22 approached the surveyors (Surveyor C and Surveyor D) and stated he had Post-traumatic Stress Disorder (PTSD), and the facility staff Did not know how to take care of people diagnosed with PTSD. Resident #22 stated he was upset about it. He stated he really was diagnosed with PTSD. They (facility staff) act like they don't know how to handle it (PTSD). Resident #22 stated the staff treated him as if he was pretending. Resident #22 stated, this is serious. Resident #22 stated he did not feel understood by the staff. The resident discussed his feelings more in depth with Surveyor D during the survey. On 09/26/2023, the Facility Assessment was reviewed by Surveyor C. Review of the Facility Assessment revealed the Assessment was updated on 08/31/2023 and reviewed with Quality Assurance Assessment/Quality Assurance Performance Improvement (QAA/QAPI) committee on 09/26/2023. On 09/27/2023, an interview was conducted with the Staff Development Coordinator who stated she was responsible for the education of the employees. The Staff Development Coordinator stated she did not provide any training on behavioral health to include Post-traumatic Stress Disorder because she was not aware of the requirement to provide that training to the staff members. She stated she had not been told that particular training was required. When asked if staff members were expected to know how to provide care for the residents accepted in the facility, the Staff Development coordinator stated yes. Resident #22 reported the facility staff did not know how to take care of him with his diagnosis of PTSD. Resident #22 reported experiencing undue stress related to the staff not taking him seriously. During the end of day debriefing on 09/27/2023, the Facility Administrator, Director of Nursing, and Corporate Nurse Consultant were informed that the Facility Assessment stated the facility accepted residents with behavioral health diagnoses. The Facility Assessment did not address education/training and competencies resources for behavioral health to include Post-traumatic Stress Disorder. On 10/03/2023 during the end of day debriefing, the Facility Administrator, Director of Nursing, Corporate Nurse Consultant, and Regional [NAME] President of Operations were informed of the findings. No further information was provided.

Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to ensure that residents who are trauma survivors receive trauma-informed care to mitigate triggers for 2 residents (Residents #22 and #53) in a survey sample of 48 residents. The findings included: 1. For Resident #53, the facility staff failed to provide trauma-informed care for a resident who has experienced sexual assault by CNA C at the facility. Resident #53 was admitted to the facility on [DATE] with diagnoses that include but are not limited to schizoaffective disorder, hemiplegia after CVA (Cerebrovascular Accident or stroke) right sided, HIV (Human Immunodeficiency Virus), Hepatitis C, and Hypertension. A review of the clinical record revealed the following: 8/10/2023 5:06 pm Transfer to Hospital Summary Note Text: Patient sent to [Hospital Name redacted] for evaluation r/t alleged assault, MD made aware. Patient verbalized understanding the reason for transfer. 8/10/2023 - 5:15 pm Health Status Note Text: Patient made a statement in regard to an assault that took place this morning, a statement was given from patient to myself dictated at 2:11 pm at the south unit nursing station. Phone call placed to nonemergent services so patient could give an official statement and press charges. 8/12/2023 4:51 - Alert Note Text: Due to safety concerns r/t behavioral issues; constant yelling and threatening staff to throw himself out of the bed when in room/bed. Administration made aware to possibly consider moving room closer to nurses' station. 8/15/2023 2:41 pm COMMUNICATION - with Resident Note Text: [name redacted] and [name redacted] spoke with [Resident #53] about his feelings today 8/15/23. Therapy reported that [Resident #53] wants to harm self, to which [Resident #53] admitted . [Resident #53] says that he can come up with a plan to harm himself [name redacted] made Dr. [name redacted] (psych) aware. 8/17/2023- 5:50 AM - Health Status Note-Note Text: Per reports, resident was suicidal during the day shift. Hourly checks done on resident throughout the shift, resident stated he had no plan or intention to commit suicide. During multiple encounter, resident was noted to be impatient, combative towards staff such as throwing water at care staff or yelling for not providing him with his needs as soon as he asked for them. Nurse provided education that he needs to give staff time to respond, also he needs to communicate with his words rather than violently/physically attempting to hit staff. Incontinent care provided every 2 hours and as needed, fall precautions followed and maintained, he is stable and resting in bed at this time. On 09/27/2023 and interview was conducted with the DON who was asked if they have psych services in the building and she stated that they did. When asked if she thought it would be beneficial for Resident #53 to have seen psych services after such an incident, she stated that she thought he did and would supply the notes from psych services. A review of the clinical record revealed that Resident #53 had an order dated 08/01/2023 that read, Psych Consult as needed however, was not seen by psych services until 08/23/2023. The visit on 08/23/2023 was not prompted by the sexual assault. A review of the psych notes revealed the following: Resident was referred today for stabilization in depressed mood. Per nurses' notes and report, resident is reported to be verbally abusive to staff, and refusing care sometimes, Resident was met in his room, in bed, calm, alert, speech clear and engaged. Resident reported in on multiple psychotropic medications to include Lithium, Haldol, Risperidone, Diazepam, Ativan, Methadone, Seroquel, Hydroxyzine and Trazadone. Reported he has not been sleeping well a night. I stay awake the whole night; I cannot sleep. Resident also reported he feels sad and depressed. On 08/23/2023 after the psych visit, the order was given for Trazadone 50mg for insomnia. On 09/28/2023 at 11:00 a.m., an interview was conducted with the Staff Development Coordinator who was asked about training for PTSD, she stated they do not tell me to train on that subject. When asked if she trained on trauma-informed care, she stated that she did not. When asked if she trained on behavioral healthcare needs related to substance abuse, she stated that she did not. When asked does your staff care for residents in this facility with any or all those issues and she stated that they do. On 10/04/2023 during the end of day meeting, the Administrator was made aware of the concerns. No further information was provided. 2. For Resident #22, the facility staff failed to provide trauma-informed care for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). Resident #22 was admitted to the facility on [DATE] with diagnoses that include but are not limited to incomplete paraplegia, PTSD, peripheral neuropathy, anxiety, history of substance abuse and smoking. On 09/25/2023 at approximately 1:00 p.m., an interview was conducted with Resident #22 who stated the facility Does not know how to deal with us, I have PTSD and they don't know how to talk to me. When asked to elaborate, he stated the facility staff are loud and rude and that triggers him to become aggressive. When asked if he has told anyone about this, he stated he has spoken to the DON and the Administrator about it, but nothing is done. Resident #22 also stated he had a substance abuse problem prior to coming to the facility and that the facility staff use that information against me. When asked what he meant by that, he stated the facility staff downplay his pain because he had a substance abuse issue prior to coming to the facility. He stated the staff have labeled him as drug seeking. On 09/28/2023 at 11:00 a.m., an interview was conducted with the Staff Development Coordinator who was asked about training for PTSD, she stated they do not tell me to train on that subject. When asked if she trained on trauma-informed care, she stated that she did not. When asked if she trained on behavioral healthcare needs related to substance abuse, she stated that she did not. When asked does your staff care for Residents in this facility with any or all those issues and she stated that they do. On 10/04/2023 during the end of the day debriefing, the Administrator was made aware of the concerns. No further information was provided.

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility failed to protect the residents' right to be free from physical abuse and sexual abuse by a staff member and failed to protect the residents from continued abuse by their perpetrator, affecting 2 residents (Resident #53 and #85) in a survey sample of 48 residents, which resulted in psychosocial harm for Resident #53. The findings included: 1. For Resident #53, the facility staff failed to protect the resident from enduring physical and sexual abuse, which resulted in psychosocial harm for the resident. On 09/26/2023, during a clinical record review of Resident #53's clinical chart the following was noted: a. Resident #53 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. b. A progress note dated 08/10/2023 at 5:06 p.m., stated, Patient sent to Saint Mary's for evaluation r/t [related to] alleged assault, MD [medical doctor] made aware. Patient verbalized understanding the reason for transfer. c. Another progress note dated 08/10/2023 at 5:15 p.m., read, Patient made a statement in regard to an assault that took place this morning, a statement was given from patient to myself dictated at 2:11 PM at the south unit nursing station. Phone call placed to nonemergency services so patient could give an official statement and press charges. On 09/27/2023, a review was conducted of the facility's investigation that had been performed. There was a written statement that was taken from Resident #53 that read as follows: Statement of [Resident #53's name redacted] patient stated that while he was asleep, he was awakened by a washcloth being placed on his face, he then heard a voice say, can you see me? Patient then says in return, I am not blind. Patient states the CNA [certified nursing assistant/CNA C] then pulled off his sheets and undid his brief and began flicking his penis back and forth. Patient states the CNA then stated he was going to shave his pubic hairs. Patient stated he began to yell out for help, which caused the CNA to abruptly stop, then pick the patient up and throw him in the chair. Patient then restated all of the above details to the speech therapist. On 09/27/2023 at 11:26 a.m., an interview was conducted with the facility Director of Nursing (DON), with the Administrator and survey team present. The DON was asked about the incident involving Resident #53 and CNA C. The DON reported, On 8/10 when I came in, the speech therapist (SLP) came and talked with me 8:30 a.m., and gave me a service concern and said she saw Resident #53 and he reported that a CNA had touched him inappropriately. I went and talked with him [Resident #53] and he said when he did foley care it was discomfort. Then at noon he said the CNA had put a washcloth over his face and he was flicking his penis back and forth. He could not give a name or describe the person, we had one male CNA working that day, she identified as [CNA C's name redacted]. I asked him [Resident #53] if he wanted to be sent out, he said yes. The DON stated that she had CNA C sent home prior to her arrival at the facility early that morning due to performance issues, prior to her knowledge of the allegation involving Resident #53. On 09/27/2023 at 12:10 p.m., an interview was conducted with Employee M, the Speech Language Pathologist (SLP). The SLP reported on 08/10/2023, she arrived to work at 7:50 a.m., and as she walked down the hall, Resident #53 got her attention and reported, the aide [CNA C] had put a washcloth on his face and he had touched his penis. I told the nurse. The SLP also stated that at about 9:30 a.m., she saw Resident #53 in the dining room being fed by the CNA who had allegedly abused Resident #53 earlier that morning. The SLP said, I saw his [Resident #53] mouth was stuffed full of food, and I saw that was way too much and he [CNA C] was getting ready to put more in his mouth. I had the resident spit it out and said that's why too much and it was the wrong diet texture, he [CNA C] said that's what they sent. I had to take over feeding the resident. The SLP reported that she reported this incident to nursing leadership and her immediate supervisor. Later that day she saw CNA C still in the facility/in passing in the hall. She was not sure of the time. The SLP said she reported the events to the Director of Nursing (DON) and wrote a statement regarding the events involving Resident #53 and CNA C. Surveyors D and F attempted to interview Resident #53 the same day, but the resident was not available for interview. On 09/28/2023 at 3:00 p.m., Surveyors D and F visited Resident #53 in his room. Resident #53 gave the same accounting of events that were in the written statement referenced earlier. There was no change in his report. The resident became very tearful and stated he was so afraid and that CNA C laid me flat in the chair on my back and was trying to silence me and say I choked on food. Resident #53 said, [Employee M's name redacted] took a picture. The resident stated that following this incident he was afraid to sleep, kept looking around, and had to be prescribed Trazadone so he could sleep. When asked how all of this made him feel, Resident #53 said, Like I wanted to leave here, I was scared, I can't move, I was afraid I was going to choke, he was trying to silence me so he could say I choked. I watched all the time. This was harm. An additional review of the clinical record revealed that Resident #53 was ordered Trazodone 50 mg tablet to be given at bedtime for sleep aid on 08/23/2023. On the afternoon of 09/29/2023, an interview was conducted with the scheduler, who stated that on the afternoon of 08/10/2023, she was told by the Director of Nursing to send CNA C home, due to complaints and work performance. Review of payroll records revealed that CNA C did not clock out and leave the premises on 08/10/2023 until 1:17 p.m. A review was conducted of the facility's abuse policy titled, Abuse/Neglect/Misappropriation/Crime/Administrative Reference Guide. Excerpts from this policy read, 1. Physical abuse: b. physical contact intentionally or through recklessness that results in, or is likely to result in, death, physical injury, pain, or psychological harm to the patient. Indications of psychological harm include a noticeable level of fear, anxiety, agitation, or emotional distress in the patient. 3. Sexual Abuse: a. sexual harassment, inappropriate touching. The policy titled, Abuse/Neglect/Misappropriation/Crime/ Patient Protection, was reviewed. This policy read, There is a zero tolerance for mistreatment, abuse, neglect, misappropriation of property, or any crime against a patient of the Health and Rehabilitation Center. 1. Patients of the center have the legal right to be free from verbal, sexual, mental, and physical abuse, corporal punishment. 2. Any employee and/or covered agent of the Center, who willfully abuses or participates in any criminal activity against any patient of the center will be immediately subjected to corrective action. On 09/27/2023 and 09/28/2023, the facility Administrator and corporate staff were made aware of the above findings. On 09/27/2023, the corporate staff notified the survey team they would be re-opening the investigation into the events involving Resident #53 and CNA C. No further information was provided. 40026 2. For Resident #85, the facility staff failed to ensure the resident's right to be free from sexual abuse. On 09/26/2023, an interview was conducted with Resident #103, who stated she knew that on 08/10/2023 Resident #85 had been molested by a male CNA. She allowed the surveyors to listen to an audio recording of CNA E questioning Resident #85. According to the audio recording, CNA E could be heard saying, Why did you let that man shave you down there. Resident #85 stated that she did not let anyone shave her to which you can hear the CNA reply You are mighty bald down there. You got less hair than me and I was waxed. On 09/27/2023 at 1:00 p.m., an interview was conducted with CNA E who admitted that she had knowledge of the incident and that she made the nurse on duty and the DON aware of the incident. On 09/27/2023 an interview was conducted with the DON who stated she did not view it as abuse and stated. Coming from [Resident #103] she was not inclined to believe her. When asked what she was supposed to do with allegations of abuse, she stated she should investigate them. When asked what she should do first, she repeated Investigate them. The DON was advised that facilities are to report first and complete the investigation is second. The DON was also advised to review the facility's policy and the State Operations Manual (SOM) on abuse reporting. The incident was not reported nor investigated until 09/27/2023 (2 days after the survey began). The incident was reported to the Office of Licensure and Certification, Adult Protective Services, the Department of Health Professions, and the Police by the Regional Director of Clinical Services. On 10/04/2023 during the end of day meeting, the Administrator was made aware of the concerns. No further information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to transfer 1 of 3 sampled residents (Resident #1) properly and as a result Resident #1 sustained a fracture. This is Harm, Past Noncompliance. The findings include: On 03/15/2023, a review of Resident #1's care plan in effect for 10/31/2022 was reviewed. The review showed that Resident #1 required a two person lift via a Hoyer lift. Review of Resident #1's clinical record showed a note dated 10/31/2022. The note read that Resident #1 was seen by the Nurse Practitioner (NP) due to complaints of pain to left leg and left shoulder after being put back to bed without hoyer lift. The NP ordered x-rays. A note dated 11/1/2022 read that Resident #1 had a comminuted mid tibial fracture and subcapital femoral neck [fracture]. The note also read that Resident #1 needed to be sent to the ER. A review of facility documentation revealed a form titled Employee Corrective Action. The form showed that Certified Nurses Assistant (CNA) B failed to perform transfer according to the resident plan of care and document mode of transfer. The form further showed that this failure resulted in harm to resident. The facility took corrective actions. The facility re-educated staff concerning transfers and documentation. The facility audited all residents care plans to make sure the care plans had the correct mode of transfer. The facility completed the corrective actions on 11/02/2022. Therefore, this deficient practice will be past non-compliance.

Based on staff interview, clinical record review, and facility documentation review , the facility staff failed to implement their abuse policy for 2 Residents (Resident #15, and 13) in a survey sample 9 Residents. In addition, the facility staff permitted a known perpetrator of abuse (CNA B) to work in the facility having direct contact with Residents on 1 of 2 nursing units. Immediate Jeopardy (IJ) was identified on 1/20/23 at 3:55 PM, at which time the facility Administrator and Director of Nursing were made aware. Following verification of the removal of immediacy the facility abated IJ on 1/26/23 at 4:07 PM. The scope and severity was lowered to a level 2, pattern. The findings included: 1. The facility staff failed to implement their abuse policy with regards to employee screening and protection of Residents, by permitting a known perpetrator of abuse/neglect (CNA B) to work in the facility having direct contact with multiple Residents who resided on 1 of 2 nursing units within the facility. This resulted in Immediate Jeopardy. A closed clinical record review was conducted 1/18/23-1/20/23. Resident #15 discharged from the facility and therefore was unavailable for interview. Review of facility documentation to include, but not limited to grievances, revealed Resident #15 and her family had reported numerous concerns of neglect and being left for extended periods of time/hours without any staff assistance for incontinence care. Specifically, it was noted that on 4/16/22, Resident #15's family reported that On 4/15/22, 3-11 PM shift the resident asked her CNA [CNA B's name redacted] to assist her to bed, the CNA told her she would put her to bed at 9 PM. CNA eventually came back at 9:45 PM complaining that the Resident interrupted her break. She deserves a break because she has been on her feet all day, at this time the Resident stated the CNA hit her in the face with the O2 [oxygen] cord unintentionally and stated that she didn't need it so long. The facility removed CNA B from the schedule and because the CNA was an agency staff member, the agency was contacted and notified of the allegation. Upon conclusion of the facility's investigation the Administrator had a Summary document which was typed and read, .The agency staff, [CNA B's name redacted] was removed from the scheduled immediately until the facility completed their investigation. After completing interviews with residents and staff it was determined that the incidence [sic] was substantiated the facility could substantiate this was a willful intent of abuse [sic]. There was a statement from the facility's Director of Nursing (DON) who indicated CNA B was placed on a DNR [do not return] status with this facility. On the afternoon of 1/20/23, Surveyor E met with the facility's scheduling coordinator/Employee P. The scheduling coordinator reviewed past records and confirmed that CNA B did not work any shifts following 4/15/22. However, a review of the facility's submitted as-worked schedules revealed that CNA B was listed as having been scheduled during the survey as recent as 1/19/23 and was scheduled to work on 1/20/23. On the afternoon of 1/20/23, Surveyor E met with the facility's human resources manager (HRM)/Employee E. The HRM was able to access and confirmed CNA B was hired by the facility on 6/27/22, as a full-time employee and remained so. The HRM also provided CNA B's timecard which revealed CNA B worked as recent as 1/19/23. The employee file for CNA B was requested and received. Upon review it was determined that CNA B disclosed a prior criminal charge of misdemeanor assault on her sworn statement completed 6/19/22. The facility Administrator and Director of Nursing who were involved in the investigation of and determination that CNA B had abused/neglected Resident #15 in April 2022, were the same individuals in those positions when CNA B was hired on 6/27/22. On 1/26/23, a review of CNA B's timecard was conducted and revealed the employee had worked a total of 90 days having direct Resident contact. Many of those days CNA B worked double shifts, therefore having access to and interaction with many Residents and potentially having an opportunity to abuse and/or neglect the Residents again. On the mid-morning of 1/26/23, Surveyor E conducted an interview with the Regional Human Resources Director (RHRD)/Employee K. Employee K stated that the facility's Administrator and Director of Nursing have a role in approving applicants for hire and should not have permitted CNA B to have been hired since they had prior knowledge of the employee's history and findings of abuse/neglect. The facility policy titled Abuse/Neglect/Misappropriation/Crime: Prevention/Screening/Training read, The Administrator promotes the prevention of abuse . and neglect and misappropriation of property by performing background checks on all employees and by advocating and enforcing patient rights . The policy also stated, 1. Criminal background and reference checks are performed on all employees . Immediately Jeopardy was identified on 1/20/23 at 3:55 PM, at which time the facility Administrator and Director of Nursing were made aware. Following this notification, CNA B was removed from the facility and clocked out at 4:08 PM. On 1/24/23 at 1:37 PM, the facility submitted an accepted IJ removal plan and on 1/26/23, submitted a revised plan which read as follows: 1. Certified Nursing Aide (CNA) B was escorted immediately to the Director of Nursing (DON) office, and the Interim Director of Nursing and Regional Director of Clinical Services (RDCS) informed CNA B regarding the incident of the substantiated allegation of abuse and that she is terminated based on history of substantiated abuse/neglect against a resident. 2. CNA B was escorted by the Interim DON to the time clock. She clocked out at 4:08pm, was escorted to her car and she was observed exiting the facility grounds. 3. The surveyors were informed of the above, and a copy given of her clock out time, on the time sheet prior to exit. 4. The Board of Nursing report completed regarding CNA B substantiated abuse/neglect allegation and the employee file reviewed with 2 other corrective actions based on care issues included on report 1/20/2023. 5. On 1/20/2023 a 100% audit of all Facility Reportable Incidents (FRIs) from past year, 2022, to current January 2023 was completed to ensure no employee is currently employed that was involved in any substantiated FRI. 6. On 1/26/2023 a 100% audit of all facility employees' files, to include agency and contracted staff, were reviewed to verify the screening process was completed by Regional Director of HR. For any employee found not in compliance, they will have direct supervision by another employee with an approved background and reference checks. 7. On 1/20/2023 interviews immediately were conducted of the residents assigned to CNA B by Social Service Director and skin checks were completed on the resident's that could not be interviewed. 8. On 1/20/2023 all current residents of the facility that have the ability to be interviewed were conducted by designated management team to identify any concerns with care and/or allegations of abuse/neglect with abuse/neglect process followed. 9. On 1/20/2023 there were 4 additional residents who were identified with allegations of abuse/neglect. The abuse policy was followed, a FRI was submitted, and the resident was protected with the identified employee(s) suspended pending investigation. 10. On 1/20/2023 residents' family members were interviewed for allegations of abuse/neglect or concerns that were associated with allegation of abuse/neglect, or grievance reports. 11. On 1/20/2023 Staff interviews were conducted for all identified/associated staff with any allegation of abuse/neglect. 12. On 1/24/2023 Staff interviews were conducted to identify concerns for abuse/neglect with any findings further investigated by the Interim Administrator, Interim DON or designee with the abuse/neglect policies followed. 13. On 1/24/2023 all other residents of the facility that do not have the ability to be interviewed had skin checks completed. 14. On 1/23/2023 the grievance concern reports, and the resident council minutes were reviewed and any identified as an allegation of abuse/neglect were reported following the abuse/neglect policy. 15. On 1/23/2023 there were 3 additional residents identified with allegation of abuse/neglect from the review of the grievance concern reports. The abuse policy was followed, a FRI submitted, and the patient was protected with the identified employee suspended pending investigation. 16. Education will be provided to the Administrator and department managers to include human resources, staffing coordinator, dietary, nursing, rehab, housekeeping, social service, business office manager, maintenance, activities, and admissions will be by Regional Director of HR regarding the hiring, prevention, and screening process of anyone involved in a substantiated allegation of abuse/neglect to identify if eligible for hiring. 17. All Facility staff, to include agency staff, will be educated on the policies to include abuse/neglect for patient protection, abuse/neglect/misappropriation/crime prevention, screening/training process, reporting and investigating, and resident rights. All staff will be educated prior to working next facility shift. 18. Administrator and department managers educated on 1/23/2023. 19. [Administrator name redacted], Administrator and [DON name redacted], DON were suspended pending investigation on 1/19/2023. 20. On 1/23/2023 [Administrator name redacted], Administrator and [DON name redacted], DON were terminated by the [NAME] President of Operations (VPO) and Regional Director of HR. 21. [VPO name redacted], VPO is the Interim Administrator and [RDCS name redacted] RN/RDCS is the Interim DON. 22. Compliance date for abatement plan 1/26/2023 at 2:51pm. The survey team verified the IJ removal plan as evidenced by the following: On 1/20/23, the survey team remained on-site until CNA B was removed from the facility and received evidence that she had clocked out and left the premises. The survey team reviewed evidence that CNA B had been reported to the Board of Nursing/Department of Health professions. The survey team reviewed the FRI's for the past year and identified any staff with a substantiated allegation of abuse/neglect and verified that they were not currently employed or working in the facility. The survey team reviewed the 100% audits conducted by the facility staff with regards to the screening documents required per the facility's abuse policy (i.e. criminal background check and references). The survey team then reviewed the as-worked schedule for the day, 1/27/23, and ensured that any staff who had outstanding screening documents were being directly supervised during Resident interactions by a staff member who had an approved criminal background check and references on file. The resident interviews conducted of the Residents assigned to CNA B on 1/20/23, were reviewed with no identified concerns noted. The Resident interviews conducted of all interviewable Residents and skin checks of non-interviewable Residents was reviewed. Concerns that were identified were noted and corresponding FRI's were submitted, which indicated the facility was implementing their abuse policy. Family interviews conducted by the facility staff were reviewed. Grievance concerns and Resident council minutes were reviewed, and the survey team confirmed that any identified concerns were being addressed as per the facility abuse policy, (any involved employee removed while an investigation was being conducted, FRI submitted, and investigation initiated) Staff interviews were conducted across all departments for line staff and management staff which included staff working off shifts (evening and nights) to ensure they had received education and knew the abuse policy. Survey team observed the Administrator and Director of Nursing being escorted from the premises and reviewed supporting evidence that their employment had been terminated. Survey team confirmed that an interim Administrator and Director of Nursing were in place and aware of and following the abuse policy as evidenced by their daily presence in the facility during the survey, as well as staff being suspending while investigations were being conducted and FRI's being submitted for identified abuse/neglect allegations IJ was verified as removed on 1/26/23 at 4:07 PM. 31199 2) For Resident #13, the facility staff failed operationalize their abuse policies to protect, report, and investigate an allegation of abuse on 10-14-2022. Resident #13's first MDS document (a federal assessment instrument) dated 9-29-22, indicated that the Resident was alert and oriented with no cognitive impairments, no memory nor mood issues, and no aberrant behaviors. Resident #13's progress notes were reviewed and revealed a fall on 10-4-22, and an incident on 10-15-22. On 1-19-23 all incident reports for the Resident were reviewed. The review revealed that the only fall prior to the 10-14-22 incident, occurred on 10-4-22. The Resident had a fall in her room getting out of bed. The Resident was in a private room and the incident was unwitnessed. The Resident was assisted off of the floor by the nursing staff and the Resident was assessed to be alert, and oriented, to time person place and situation, with no injuries. The second incident occurred ten days later on 10-14-22 a Certified Nursing Assistant (CNA) found the Resident sitting on the side of her bed at approximately 8:00 p.m. with a bloody face and golf ball sized raised area in the center of the Resident's forehead, with a moderate amount of blood on the Residents face, sheets, and floor. The document stated the physician was notified and ordered the Resident be sent to the emergency department for evaluation. The Resident stated that on 10-14-22 she had been hit on the head and knocked to the floor where she was beaten by someone, and she stated that she could not identify who the perpetrator was as she had lost consciousness. She stated she thought it was a man. The Resident indicated she told the facility staff someone had hit her in the head and beat her and asked the facility supervisor nurse on 10-14-22 to call police immediately after the incident and they refused. The Resident was discharged back to the facility on [DATE]. The Resident stated she was scared to return, however, she wanted to see if she could identify the person responsible and get therapy to strengthen herself before going home. After returning to the facility and having no help to find the perpetrator, she called police herself and made a report on 10-27-22. The Resident stated that three to four days after seeing the police on 10-28-22 and making a report, the Director of Nursing (DON) called the Resident to her office and wanted to know what the Resident had called the police about. The Resident stated she told the DON exactly what she said to the police. Resident #13's clinical record was reviewed for Social Work notes, and none were found. On 1-19-2023 an interview was conducted with the Administrator and Director of Nursing (DON) and asked what their policy was on allegations of abuse. They stated all persons alleging abuse must be protected, and an investigation started immediately, and the incident had to be reported per law. They were asked for the investigation and reporting completed for Resident #13, and they stated she alleged a man had attacked her, and there were no men working on the day of the incident according to their investigation. However, on 1-26-23 the time clock punches for all staff were requested for 11-14-22 and received. The documents revealed 7 males working on that day. On 1-20-23, the facility staff provided a copy of their policy entitled, Abuse/neglect/misappropriation/crime Reporting requirements/investigations #703. In section 1 .The Administrator will immediately report to the State Agency, but not later than 2 hours after the allegation (of abuse) is made, if the events that caused the allegation involves abuse or results in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury. In Section 2 The Administrator and/or DON will immediately initiate a thorough internal investigation of the alleged/suspected occurrence. In policy #704 of the abuse neglect policies, under procedure section 2, injuries of unknown origin should be handled the same as an allegation of mistreatment, neglect or abuse, and must be reported to the state agency. On 1-24-23 at approximately 3:30 P.M., the Corporate Nurse Consultant and Regional Director of Operations were notified of findings. Both agreed that this incident should have been reported and investigated as an allegation of abuse. No further information was provided by the facility.

Based on interview, record review, review of policies and procedures, and review of the Centers for Medicare and Medicaid Services (CMS) QSO 20-38-NH Revised memo, the facility failed to implement outbreak testing of staff and residents to prevent the spread of COVID-19 upon identification that a North Wing Unit Manager (NWM) tested positive for COVID-19 on 09/03/21. This failure increased the likelihood of COVID-19 transmission to the 82 residents living at the facility. As of 09/08/21 at 7:01 PM, the facility had not begun outbreak testing per CMS guidance. On 09/08/21 at 7:39 PM, the Administrator was notified that the failure to ensure that all residents and staff were tested for COVID-19, regardless of vaccination status, after the facility was notified on 09/03/21 that the NWM tested positive for COVID-19, constituted immediate jeopardy at F886-L: COVID 19 Testing Residents and Staff. The facility provided an acceptable removal plan for the immediate jeopardy at F886-L on 09/10/21. The removal plan for F886-L included: 1. testing of all residents and staff, regardless of vaccination status, completed on 09/09/21; 2. continued testing of all COVID negative staff and residents, regardless of vaccination status every 3-7 days until testing identified no new cases of COVID 10 infections among residents for staff for a period of at least 14 days since the most recent positive case of 09/03/21; 3. staff to be notified of testing dates by a memo at the front entrance and time clock; 4. the Director of Nursing (DON) or designee to document test results of staff and residents on a line list log, the line list will be reviewed by the DON or designee for positive results, and any positive staff or residents will restart the outbreak testing guidelines; and 5.the Infection Preventionist, the DON and the Administrator were educated by the Nurse Consultant on COVID testing requirements and appropriate documentation of the testing results on 09/09/21. The survey team conducted the following to verify implementation of the removal plan for F886-L: 1.The survey team reviewed the testing logs for all the residents and staff completed on 09/09/21. 2.There were no positive results for the residents and/or staff from the 09/09/21 testing to reset the duration of the outbreak testing at the time of the survey. 3.The survey team observed the posting for staff testing dates. 4.The survey team reviewed the testing/results line list log from 09/09/21. 5. The survey team reviewed the education provided by the Nurse Consultant on COVID testing and documentation. The immediate jeopardy was removed on 09/10/21 at 3:50 PM. The deficient practice remained at an F scope and severity (potential for more than minimal harm) following the removal of the immediate jeopardy. Findings include: Review of facility policy titled, COVID-19 Testing, dated 05/04/21, revealed COVID-19 testing will be performed by trained personnel following CMS recommendations for testing . Outbreak testing for employees and patients: a. An outbreak is defined as a new COVID-19 infection. Upon identification of a single new case of COVID-19 infection in any employee or patient, testing is indicated. b. Outbreak testing of all employees and patients will occur as soon as possible when a new case is identified, regardless of vaccination status. Retesting of negative individuals will occur every 7 days until testing identifies no new cases of COVID-19 infection among employees or patients for a period of at least 14 days since the most recent positive result. Review of Centers for Medicare & Medicaid Services (CMS), Ref: QSO-20-38-NH, dated 04/27/21, revealed . For outbreak testing, all staff and residents should be tested , regardless of vaccination status, and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result . Documentation of testing: Symptomatic patients and employees- document the date(s) and times(s) of the identification of signs or symptoms, when testing was conducted, when results were obtained, and the actions the Center took based on the results. Identification of a new COVID-19 case in the Center-document the date the case was identified, date that all other patients and employees were tested , and the dates that all negative patients and employees were retested .For routine unvaccinated employee testing, document the centers county positive rate, corresponding testing frequency, and the date each positivity rate was collected, as well as date(s) that testing is performed . During the entrance conference on 09/08/21 at 09:00 AM, the Administrator indicated that the facility currently had one staff member out of work that tested positive for COVID-19 during a weekly COVID-19 test on 09/03/21. The Administrator further indicated the entire staff and residents were tested on [DATE] and all results were negative. The facility was unable to provide evidence that the residents and staff were tested for COVID-19 on 09/03/21. During an interview on 09/08/21 at 10:43 AM, the Infection Preventionist (IP) stated that the facility did not perform any COVID testing on 09/03/21. The IP stated that she is required to report the test results to the Department of Health (DOH). Upon asking the DOH for evidence of facility testing, the IP received an email indicating that the DOH was unable to provide any specific information about submitted results. On 09/08/21 at 11:35 AM an interview with Certified Nursing Assistant (CNA) 2 was conducted. CNA2 stated I have not been tested in the last two weeks. During an interview on 09/08/21 at 11:39 AM, with two residents (Resident (R) 6 and R52) was conducted. Both stated they were tested last week but neither could remember the exact day. Review of a R6's electronic medical record (EMR) significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/05/21 revealed a Brief Interview for Mental Status (BIMS) of 14 out of 15 indicating intact cognition. Review of R52's EMR quarterly MDS with an ARD of 08/10/21 revealed a BIMS of 14 out of 15 indicating intact cognition. Interview with North wing Licensed Practical Nurse (LPN)1 on 09/08/21 at 11:42 AM indicated that she was given a facemask and face shield upon entrance to the facility but was not informed that the facility was in outbreak status. During an interview with the Director of Nursing (DON) and Administrator on 09/08/21 at 10:14 AM, the DON confirmed that the facility could not provide evidence that the residents and staff members were tested for COVID-19 after a staff member tested positive on 09/03/21. The DON indicated that it was the IP who kept the testing logs of both staff and residents. The facility was unable to provide any line listings of staff and/or resident testing prior to the survey team leaving the facility on 09/09/21 at 10:00 PM.

Based on interviews, record review, review of facility policy, and review of Center for Disease Control and Prevention (CDC) guidelines, the facility failed to initiate appropriate Personal Protective Equipment (PPE) to include N95 and eye protection for all staff, failed to initiate quarantine of residents during an outbreak, and failed to ensure all staff, visitors, and vendors were screened for COVID-19 signs and symptoms prior to entrance into the facility. These failures had the likelihood of increasing the risk of transmission of COVID-19 to all residents. Based on interviews, observations, and review of facility policy, the facility failed to ensure staff performed hand hygiene during meal delivery. On 09/08/21 at 7:39 PM, the Administrator was notified that the failure to ensure all staff were wearing appropriate PPE for outbreak status after the facility was notified on 09/03/21 that a staff member tested positive for COVID-19, failure to initiate quarantine of residents during an outbreak, and failure to screen all staff, visitors, and vendors constituted immediate jeopardy at F880-L: Infection Control. The facility provided an acceptable plan for removal of the immediate jeopardy for F880-L on 09/10/21 that included staff education regarding the appropriate PPE to wear during outbreak status to include an N95 mask and eye protection in the entire building, the entire North Wing Unit was placed on droplet precautions, and staff education on screening. The survey team conducted the following to verify implementation of the removal plan for F880-L: 1.The survey team conducted observations of staff on wearing the required PPE for Transmission Based Precautions (TBP) during an outbreak. 2. The survey team conducted interviews with staff on education concerning the required PPE and TBP during an outbreak. 3.The survey team observed signage indicating the facility was in an outbreak status. 4.The survey team observed signage and PPE indicating residents on the North Wing Unit were under quarantine. 5.The survey team reviewed inservice information on screening and PPE usage. 6. The survey team conducted interviews with staff to validate their understanding on screening requirements. The immediate jeopardy was removed on 09/10/21 at 3:50 PM. The deficient practice remained at an F (potential for more than minimal harm) scope and severity following the removal of the immediate jeopardy. Findings include: Review of CDC's Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, dated 02/23/21 states, New Infection in Healthcare Personnel or Resident . Because of the high risk of unrecognized infection among residents, a single new case of [CONDITION(S)]-CoV-2 infection in any HCP or a Nursing Home-onset [CONDITION(S)]-CoV-2 infection in a resident should be evaluated as a potential outbreak . HCP should care for residents using an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown . Residents should generally be restricted to their rooms and serial [CONDITION(S)]-CoV2 testing performed . Establish a Process to identify and Manage Individuals with Suspected of Confirmed [CONDITION(S)]-CoV-2 Infection. Ensure everyone is aware of recommended IPC practices in the facility. Post visual alert (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) with instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene). Review of facility policy titled COVID-19, effective date 06/30/21, revealed, Surveillance -Employees. Screen Center employees prior to beginning shift to include Positive travel history to locations with sustained community transmission of COVID-19 withing the past 14 days. Signs or symptoms of COVID-19 (temperature greater than 99.5 degrees F or 37.5 degrees C), chills, sore throat, cough, nasal congestion, congestion, runny nose, fatigue, myalgia, body aches, shortness of breath, difficulty breathing, headache, nausea, vomiting, diarrhea, or new loss of [NAME] or smell). Review of the facility policy titled, COVID-19 Plan undated revealed: Employee screening: 100% screening of all staff entering the center at the beginning of each shift . During the entrance conference on 09/07/21 at 09:00 AM, the Administrator indicated that the facility currently had one staff member out of work that tested positive for COVID-19 during a weekly COVID-19 test on 09/03/21. Upon entry to the facility on [DATE] at 09:00 AM, no signs were observed on the facility entrance indicating that the facility was in outbreak status. During an interview with the Director of Nursing (DON) and Administrator on 09/08/21 at 9:45 AM, both the DON and Administrator were observed wearing surgical masks and not the required N95 mask and eye protection as required per CDC guidelines during an outbreak status. At this time the DON was unable to indicate what precautions should be put into place after a staff member and/or a resident tests positive for COVID-19.Per the CDC guidance during outbreak status facility is to implement N95 masks and eye protection for all staff, staff is to wear all PPE (N95, eye protection, gowns, and gloves) when caring for residents who have been exposed, residents are to remain in their rooms unless wearing a face mask and practicing social distancing in common areas, and to post signs indicating outbreak status with required PPE. During an interview on 09/08/21 at 10:00 AM, the Infection Preventionist (IP) indicated that she was in the building working on 09/03/21 and was not notified of a staff member that tested positive for COVID-19, and had she been notified she would have begun CDC recommendations for outbreak status to include, posting signs of the outbreak on the front door, initiating appropriate PPE to include N95 and eye protection, initiating droplet precautions for the unit the staff member was on, and interviewing the NWM as to where she came in, what her symptoms were, and who she came into contact with. Observations from 09/08/21 at 9:45 AM through 09/09/21 at 10:00 AM revealed staff on the North Wing wearing surgical masks, not N95 face masks, and no eye protection despite the facility being in an outbreak. It took surveyor intervention on 09/09/21 at approximately 10:00 AM for the facility to implement the CDC guidelines during an outbreak. During an interview on 09/10/21 at 11:07 AM, Registered Nurse (RN)1 indicated she was in serviced that morning [09/10/21] about what PPE is required during an outbreak this morning. During an interview on 09/10/21 at 11:39 AM, CNA 3 indicated she was at approximately 10:00 AM as to the appropriate PPE to wear during an outbreak status to include N95 mask, eye protection and using droplet precautions when in residents' rooms. During a telephone interview on 09/10/21 at 5:00 PM, the North Wing Unit Manger (NWM) stated that at approximately 10:00 AM on 09/03/21 there was an announcement for the weekly COVID-19 testing in the dining room. NWM stated she tested positive during the rapid [MEDICATION(S)] test and the DON then did a PCR test and immediately sent her home. The NWM further stated that she does not screen herself at the entrance and she thought the screening Kiosk was for visitors. She stated she used it the day of her interview and thought that after she was hired, she was not a visitor anymore. VWM further indicated that no one instructed her to screen before entering the facility. VWM stated she was not instructed on the screening process. During an interview on 09/09/21 at 4:41 PM, the Administrator indicated that she was unable to find any evidence that NWM screened for signs of COVID-19 prior to working a shift since July 2021. The Administrator was asked to provide to the survey team all screening logs for the facility for the months of July, August, and September 2021. By the end of survey on 09/10/21 at 10:00 PM the Administrator was unable to provide screening logs. During an interview on 09/09/21 at approximately 5:45 PM, the DON stated that staff are educated upon hire that they are supposed to screen themselves before entering the building, either by using the electronic Kiosk in the front of the building, or the paper form in the back of the building. The DON stated there was no written staff screening policy and procedure, and that it's done verbally, with no paper documentation to indicate staff screening was done. 2. The facility failed to ensure staff performed hand hygiene during meal delivery. On 09/07/21 at 12:20 PM multiple observations of Certified Nursing Assistant (CNA) 3 were conducted. CNA3 was observed delivering lunch to Resident (R) 74, R24, R50, R67, R44, R62, and R23. CNA3 was observed pushing the food cart, opening the doors of the food cart, handling multiple trays for other residents, and touching his clothes. CNA3 failed to perform hand hygiene of any kind (ABHR, hand washing) between the handling of the residents' food trays. On 09/07/21 at 12:20 PM multiple observations of CNA5 were conducted. CNA5 was observed delivering lunch to R16, R59, R2, R22. CNA5 was observed pushing the food cart, opening the doors of the food cart, handling multiple trays for other residents, and touching her clothes. CNA5 failed to perform hand hygiene of any kind (ABHR, hand washing) between the handling of the residents' food trays. On 09/07/21 at 12:20 PM multiple observations of CNA1 were conducted. CNA1 was observed delivering lunch to R3, R71, R6, R52 and R79. CNA1 was observed pushing the food cart, opening the doors of the food cart, handling multiple trays for other residents, and touching her clothes. CNA1 failed to perform hand hygiene of any kind (ABHR, hand washing) between the handling of the residents' food trays. On 09/07/21 at 12:35 PM an interview with CNA1 was conducted. CNA1 stated, I was not taught to sanitize between trays. On 09/07/21 at 12:37 PM an interview with CNA5 was conducted. CNA5 stated, I was not taught to sanitize between trays. On 09/07/21 at 12:45 PM an interview with CNA3 was conducted. CNA3 stated, I'm supposed to wash hands in between trays, but I don't touch anything (doors, tables, etc.) I only handle the trays, so I don't need to wash. Observation on 09/07/21 at 12:05 PM, revealed Certified Nursing Assistant (CNA) 4 removing a food tray from a food cart stationed in the hallway, entering room [ROOM NUMBER], and delivering a food tray to the resident in bed B. CNA4 failed to perform hand hygiene before entering room [ROOM NUMBER]. CNA4 was further observed leaving room [ROOM NUMBER] and obtaining another food tray from the food tray cart in the hallway. CNA4 delivered the food tray to the resident in bed A room [ROOM NUMBER]. CNA4 failed to perform hand hygiene after delivery the tray to the resident in bed A. CNA4 was observed to exit room [ROOM NUMBER] and obtain a food tray for the resident in room [ROOM NUMBER] bed B. CNA4 failed to perform handwashing before and after the delivery of two food trays to the two residents in the room [ROOM NUMBER]. Continued observation revealed CNA4 leaving room [ROOM NUMBER], proceeding to the food cart, and retrieving a food tray for room [ROOM NUMBER]. No hand hygiene was performed. CNA4 entered room [ROOM NUMBER] and donned (put on) gloves. CNA4 failed to perform hand hygiene before entering resident's room [ROOM NUMBER] and before donning gloves. After donning gloves, CNA4 set up the food tray for the resident in room [ROOM NUMBER] bed A. When set-up was completed, CNA4 doffed (removed) the gloves and left the room without performing any handwashing. CNA4 retrieved a food tray from the food cart, returned to room [ROOM NUMBER], and delivered the food tray to the resident in B bed. No hand hygiene was performed. CNA4 was then observed retrieving the food tray from the resident in the B bed in room [ROOM NUMBER] and returning the tray to the food cart. When asked why, CNA4 stated that the resident in 57B had her own food and had declined the food tray. No handwashing was performed throughout the preceding observations. CNA4 proceeded to retrieve a food tray for the resident B bed in room [ROOM NUMBER]. CNA4 donned gloves to assist the resident in 58B with the tray. CNA4 discarded gloves, left room [ROOM NUMBER], entered room [ROOM NUMBER], and failed to perform hand hygiene in between assisting the residents in room [ROOM NUMBER] and 59. Next, CNA4 entered room [ROOM NUMBER] (only one resident in the room) with a food tray, donned gloves, and began to feed the resident in the A bed. No hand hygiene was performed before entering the room, donning gloves, and feeding the resident. CNA4 doffed the gloves and left room [ROOM NUMBER] for the pantry to pick up a can of soda for the resident in bed A in room [ROOM NUMBER]. No hand hygiene was performed. CNA4 reentered room [ROOM NUMBER]A and gave the soda to the resident in room [ROOM NUMBER]. CNA4 donned gloves without performing hand hygiene and continued to feed the resident in bed A room [ROOM NUMBER]. CNA4 doffed gloves and left the room for the nurse's station to get a telephone. Upon returning to the room, CNA4 donned gloves and assisted the resident to make a phone call. With the same gloves still on, CNA4 wet a washcloth and cleaned the resident's face. After cleaning the resident's face, CNA4 discarded the gloves and was observed washing her hands at the sink in room [ROOM NUMBER]. In an interview with CNA4 on 09/07/21 at 12:45 PM, CNA4 stated that she was a TNA (Nursing Assistant in training) and had been a TNA with the facility for about 6 months, training to get her certification as a CNA. CNA4 was told that during observations for the prior 45 minutes that she had been observed going in and out of residents' rooms without performing hand hygiene and only performed hand hygiene one time at 12:45 PM in room [ROOM NUMBER]. CNA4 stated that she only just came on duty and that she had used sanitizer. When CNA4 was told that she had not been observed using hand sanitizer, she gave no further responses. A review of the facility's policy titled Infection Prevention & Control Policies & Procedures-Handwashing Requirements, Policy Number 401, Effective Date 02/06/20, revealed that: All staff are trained in proper technique upon hire, annually, and PRN, and are monitored for proper handwashing practices. Employees will wash hands at appropriate times to reduce the risk of transmission and acquisition of infections . Hand hygiene can consist of handwashing with soap and water or use of an alcohol-based hand rub (ABHR). A. Hand Hygiene l. The following is a list of some situations that require hand hygiene: a. When coming on duty. b. When hands are visibly soiled (handwashing with soap and water); before and after direct patient contact (for which hand hygiene is indicated by acceptable professional practice) e. Before and after eating or handling food (handwashing with soap and water) f. Before and after assisting a patient with meals (handwashing with soap and water) g. Before and after assisting a patient with personal care (e.g., oral care. bathing) r. After removing gloves or aprons s. After completing duty

Based on staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to provide adequate supervision to prevent a fall with injury, resulting in harm, for 1 Resident (Resident #20) in a survey sample of 23 residents. Specifically, Resident #20 was left unattended and fell from a bed during perineal care resulting in Resident #20 being sent to the hospital and receiving 4 sutures above the left eyebrow. The findings included: Resident #20 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #20's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 12/09/2013 coded Resident #20 with short-term memory problems, long-term memory problems, and with severely impaired cognitive skills for daily decision-making. In addition, the Minimum Data Set coded Resident #20 requiring total dependence, on staff, for Activities of Daily Living care and as having Range of Motion impairment to both sides of the upper and lower extremities. A review of Resident #20's clinical record was conducted during the survey. The review showed a nursing note dated 01/08/2014. The note read that Resident #20 was observed lying on the floor after falling out of bed during Activities of Daily Living (ADL) care. The note read that Resident #20 hit the left side of her head and acquired a 2-inch laceration. The note read that hospice was notified. The note read that the hospice Registered Nurse came and examined Resident #20 and agreed that Resident #20 should be sent to the hospital. The note read that Resident #20 left for the hospital at 10:00 p.m. The review showed a nursing note dated 01/09/2014. The note read that Resident #20 had returned from the hospital at 3:40 a.m. and that Resident #20 had 4 sutures above the left eyebrow. A review of the facility's investigation into the fall on 01/08/2014 was conducted. The review showed a hand written statement by Certified Nursing Assistant-A (CNA-A). CNA-A was assigned to Resident #20 on 01/08/2014. The statement read, " On January 8, 2014 at 7:25 p.m., I (CNA-A) attempted to provide care on (Resident #20) by changing her brief in order to apply a new one. I first, went to the sink in order to wet my wash cloths. After that I pulled both of her curtains to provide privacy and raised her bed to my waist level. As I pulled her sheets back in order to take off the soiled brief I noticed that she made a large liquid bowel movement. I turned her over to her left side first in order to clean that side and then turned her on her right side in order to finish cleaning her up on that side. As I was wiping, I suddenly ran out of wash cloths and quickly ran to the sink to get more. When I turned back to return to her aide, I noticed that she was on the floor in a cradled position with her head facing the sink and her feet facing the bedside dresser. I ran out to the hallway in order to quickly retrieve a nurse and hopefully a couple of others. We quickly got her back into bed and discovered a laceration on the (right (striked through)) left side of her face beside her eye. " The review showed a typed statement. The statement was titled, " (CNA-A's) statement regarding (Resident #20's) Fall. " The statement read, " On January 8, 2014 I decided that I wanted to work on the long term care unit in order to pick up some extra hours. I normally work on the skilled unit, so I am not used to patients on the long term care side. When I came in I did not receive a report on the set of people that I was assigned to, had not taken care of some of them before, and on my resident list paper it did not specify that two people were needed in order to take care of (Resident #20). At around 7:25 pm I went in to change (Resident #20); aware that she was a total care patient because her arms and legs were much contracted and she could not move without extensive assistance. She is a woman who is bigger than me but I have adapted to taking care of heavy patients by myself so I did not see her size or condition as a potential hazard to her or myself while I was in the process of providing care. Before I was to provide care for her I got my wash cloths ready, pulled the curtain, and raised her bed up to my waist level. (Resident #20) has made a large liquid bowel movement so I turned her on her left side first in order to clean up that side, and I turned her back towards my side in order to finish cleaning her up. While she was on her right side I ran out of wash cloths and ran to the sink in order to get my extra washcloths. Before I could make it back to her aide, she rolled from the bed to the floor. I was not informed until after the incident that she often rolls while someone is providing care for her. I am truly sorry for (Resident #20's) fall and I, in no way intentionally tried to hurt or harm her in any way. " The review showed a document titled, " Employee Corrective Action " dated 01/09/2014. The document read that CNA-A was suspended because, " On 1/8/14, Employee failed to follow policy and procedure. resident sustained [REDACTED]. " The document also read that on 01/16/2014 CNA-A's employment was terminated. The review showed a document titled, " Post Fall Assessment " dated 01/08/2014. The document read that " resident was being change by CNA when she slide to the floor holding on to rail. " In addition the document read, " CNA was instructed to make sure resident is in the middle of bed during changing. " The review showed a document titled, " Investigative report " dated 01/13/2014. The report read that Resident #20's bed had an air overlay mattress along with a 9000 mattress. The report stated these mattresses contributed to the fall because they caused Resident #20's body to shift while on her side. An interview was conducted with the Director of Nursing on 06/05/2014 at approximately 11:40 p.m. The Director of Nursing stated that Resident #20 could hold on to the rail while being changed and that CNA-A employment was terminated because CNA-A's handwritten statement and typed statement conflicted. The facility administration was informed of the findings during a briefing on 06/05/2014 at approximately 11:40 p.m. The facility did not present any further information about the findings. Harm deficiency. Complaint deficiency.

Based on observation, resident interview, staff interview, facility document review, clinical record review and in the course of complaint investigation, the facility staff failed to accurately assess a significant decline in condition after a fall and to send out to the emergency room (E-R) , in a timely manner for one resident (Resident #1) of three residents in the survey. And the facility staff failed to follow physician orders [REDACTED].#3) of three residents in the survey sample. 1. For Resident #1, the resident fell on her face on the floor and was found with swelling above her right eye and her blood pressure was elevated. Resident #1 was at risk for bleeding and hemorrage because of the prescribed [MEDICATION NAME] and [MEDICATION NAME] medications and her past medical history. The staff failed to send out to the E-R timely after the fall. 2. And staff failed to follow physician orders [REDACTED].#3 and the facility staff failed to provide services to assess and provide timely services for Resident #1 a. Resident #1 had a physician orders [REDACTED].#1. Accu Checks were not performed/available on 2 occasions. b. And Resident #3 had a physician order [REDACTED]. Resident #3 was observed receiving Oxygen at 3 L/min on several occasions. The finding included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Past Surgical History in 2012 included Extra-Ventricular Drainage (EVD) and Craniectomy and Dobhoff [DEVICE] placement. Facility staff was in the process of developing Resident #1's Minimum Data Set (an assessment protocol). Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Past Surgical History in 2012 included Extra-Ventricular Drainage (EVD) and Craniectomy and Dobhoff [DEVICE] placement. Facility staff was in the process of developing Resident #1's Minimum Data Set (an assessment protocol). POS (physician's orders [REDACTED]. "Physical Therapy-evaluation order physical therapy evaluate and treat." POS dated 10/10/2012, medications for Resident #1 included but not limited to: "[MEDICATION NAME] 7.5 mg (milligram) tablet 1 tab peg tube daily" (an anticoagulant). (Anticoagulants. Side effects included but not limited to bleeding. "Nursing Implications: Assess patient for signs of bleeding and hemorrhage". Source: "Davis's Drug Guide For Nurses, Eighth Edition, pages 1067-1068". "[MEDICATION NAME] 100 mg prefilled syr (syringe) 1 ml (millilteter) sq (subcutaneous) every 12 hours" (an anticoagulant). Anticoagulants: Side effects included but not limited to bleeding. "Nursing Implications: Assess patient for signs of bleeding and hemorrhage; bleeding from surgical site. Notify physician if these occur". Source: "Davis's Drug Guide For Nurses, Eighth Edition, pages 467-469". A hematoma, according to "Lippincott Manual of Nursing Practice, eighth edition, pg. 1149", is a "well defined pocket of blood and fluid beneath the skin". Physical Therapy Evaluation for Resident #1 dated 10/12/2012 documented: "Pt (patient) is limited with safety awareness, strength, functional ROM (range of motion), and indep (independence) with necessary functional mobility; she will benefit from PT (physical therapy) to increase indep and safety with functional mobility to prepare for safe d/c (discharge) home." Incident/Accident Report for Resident #1 documented: "Date of Incident:10/15/2012 Time of Incident: 4:10 a.m. Description of Incident: Resident found on floor face down by staff-beside window." Nurse's Notes for Resident #1 dated 10/15/2012 at 04:34 a.m. documented: "Resident found on floor face down beside bed close to window by staff. Assisted back into bed by staff. Vital signs 97.0, 20, 77, 187/97. When examining resident note with swelling above right eye. Neuro checks started. ROM within normal limits. Neuro checks at baseline. Called (Facility Physician), stated to apply ice to swelling above eye and may send to ER (emergency room ) if in a lot of pain. RP (responsible party) made aware." Physician's Telephone Orders for Resident #1 dated 10/15/2012 documented: "Apply ice bag to right upper forehead. May send to ER (emergency room ) if pain persist". Neurological assessment dated [DATE] at 4:10 a.m. included but not limited to: Blood Pressure (BP): 187/97 BP at 4:25 a.m.-176/91 BP at 4:40 a.m.-166/88 BP at 4:55 a.m.-173/81 BP at 5:25 a.m.-187/83 BP at 5:55 a.m.-189/87 BP at 6:25 a.m.-192/92 BP at 6:55 a.m.-230/111 On 10/18/2012 at 1:10 p.m., an interview was conducted with Registered Nurse-A (RN-A), Staff Development Coordinator. Surveyor asked Resident #1's baseline BP. RN-A stated it was 147/75, based on Resident #1's Admission Falls Risk assessment dated [DATE]. According to "Fundamentals of Nursing by Ruth F. Craven & Constance J. Hirnle, Fourth Edition, pages 444", "normal systolic blood pressure for adult ranges from 90-140 mm Hg, normal diastolic blood pressure for adult ranges from 60-90 mm Hg". According to the Facility Transfer Form, Resident #1 was sent to theER on [DATE] at 7:00 a.m.. ER (emergency room ) report for Resident #1 dated 10/15/2012 documented: "Diagnoses: [REDACTED]. Review of Systems Gastrointestinal: Positive for vomiting. Skin: +bruising and swelling to right forehead. Patient non-verbal at baseline. Physical Exam Hematoma right forehead with swollen right eye. Right periorbital ecchymosis. Neurological: She is unresponsive. Skin: Puncture wound right [MEDICATION NAME] with associated contusion". ER report for Resident #1 dated 10/15/2012 documented: "Procedure Note-Orotracheal Intubation: Indication for procedure: impending [MEDICAL CONDITION] and impending airway compromise". ER report for Resident #1 dated 10/15/2012 documented: "Progress Note-Critical Care: The reason for providing this level of medical care for this critically ill patient was due to a critical illness that impaired one or more vital organ systems (Brain) such that there was a high probability of imminent or life threatening deterioration in the patients condition. This care involved high complexity decision making to assess, manipulate, and support vital system functions, to treat this degree vital organ system failure and to prevent further life threatening deterioration of the patient's condition". On 10/17/2012 at 1:00 p.m., an interview was conducted with Licensed Practical Nurse-B (LPN-B) via phone. LPN-B was assigned to Resident #1 for the 11:00 p.m. to 7:00 a.m. shift on 10/15/2012. LPN-B stated Resident #1 was found on floor faced down at approximately 4:10 a.m., and was sent to the hospital around 7:00 a.m.. LPN-B stated Resident #1 had a hematoma above her right eye, "It's the size of a goose egg." LPN-B stated she did not send Resident #1 to the hospital immediately after her fall, because "She did not appear to be in pain." LPN-B also stated she had to pass medications to other residents that morning. Surveyor asked how Resident #1 normally communicate her needs/pain level, LPN-B stated "She doesn't, she can blink her eyes." On 10/17/2012 at 1:30 p.m., an interview was conducted with LPN-C via phone. LPN-C was assigned to Resident #1 for the 7:00 a.m. to 3:00 p.m. shift on 10/15/2012. LPN-C stated she saw Resident #1 that morning around 6:50 a.m., with a hematoma on her forehead. "It's the size of an egg." LPN-C stated Resident #1's BP was 230/111, and was vomiting. "She has to go." According to LPN-C, she instructed LPN-B to call 911. On 10/17/2012 at 3:30 p.m., an interview was conducted with Registered Nurse-A (RN-A), Staff Development. Surveyor asked to see Resident #1's care plan. RN-A stated Resident #1 should have a care plan for "Potential for Falls" due to [MEDICAL CONDITION] diagnosis. RN-A also stated "I don't see one, but she should have a Fall care plan." On 10/17/2012 at 3:40 p.m., an interview was conducted with Facility Physician. Facility Physician stated Resident #1 should be on Fall Precautions. Facility Physician stated Resident #1 had history of stroke and was on anticoagulants. On 10/17/2012 at 4:00 p.m., an interview was conducted with Nurse Consultant. Nurse Consultant stated "We did not do a Fall care plan on her (Resident #1), we should have." On 10/17/2012 at 4:25 p.m., an interview was conducted with Certified Nurse Aid-A (CNA-A) via phone. CNA-A was the one who found Resident #1 faced down on the floor on 10/15/2012. CNA-A stated Resident #1's bed was not in the lowest position when she found Resident #1. Resident #1's bed was approximately 2 feet from the floor, according to CNA-A. CNA-A explained and demonstrated how the bed would roll; when it was put to the lowest position. CNA-A stated she was in Resident #1's room at approximately 4:00 a.m. on 10/15/2012, passing out wash cloths. CNA-A noticed Resident #1's feet were "dangling" at this time, therefore, she put Resident #1's feet back on the bed, and left the room. According to CNA-A, Resident #1 also had a "wedge" on her left side, to prevent her from rolling onto the area that was being treated. "There's a red area near her bottom." CNA-A said there were no floor mats nor alarm in place for Resident #1. CNA-A stated at approximately 4:15 a.m., when she was passing ice, she heard a "boom" sound, "very loud noise". First, CNA-A went into room [ROOM NUMBER], residents in room [ROOM NUMBER] were fine. Then CNA-A went into room [ROOM NUMBER], that's when CNA-A discovered Resident #1 on the floor faced down. CNA-A notified LPN-B of her findings. 3 staff members assisted Resident #1 back to bed. According to CNA-A, Resident #1 put her hand on forehead, "A minute later, her right eye was all swelled up, it was as big as an egg." "It gets bigger within minutes." CNA-A stated she notified LPN-B multiple times that Resident #1's BP was high, and right eye was "shut closed." "But I am just a CNA." According to CNA-A, LPN-C came in and saw Resident #1 around 6:50 a.m. and that's when LPN-C said "Send her out." On 10/18/2012 at 1:10 p.m., an interview was conducted with RN-A. RN-A stated she would send Resident #1 out immediately after the incident happened on 10/15/2012, if she was on duty, based on the fact that Resident #1's medical history. RN-A stated Resident #1 had history of [MEDICAL CONDITION], procedures done on the brain, hypertension, and currently on anticoagulants. "I would send her out immediately." On 10/18/2012 at 3:15 p.m., an interview was conducted with LPN-D. LPN-D stated Resident #1 had prior falls at home, 2 subdural hematoma and history [MEDICAL CONDITION]. "I will not wait 3 hours, I will send her out immediately." On 10/18/2012 at 3:25 p.m., an interview was conducted with LPN-E. LPN-E stated Resident #1 had history [MEDICAL CONDITION] subdural hemorrhage. "I would not wait 3 hours to send her out." LPN-E also stated Resident #1 should have floor mats and low bed. On 10/19/2012 at 11:40 a.m., an interview was conducted with RN-A, Staff Development. RN-A stated, "We are putting in place the POC (plan of correction)/care plan on Falls after you told us the issues." Facility Policy and Procedure titled "Falls" dated 10/12/2011 included but not limited to: "Communication of fall risk and interventions to direct caregiving staff -Care Plan Development with ongoing input from the Falls Interdisciplinary Committee -Assess, intervene, and promptly provide the necessary interventions for any resident experiencing a fall. -Notify the physician, responsible party, and/or EMS (emergency medical service), as well as the Supervisor/Administrative personnel as appropriate". Facility Policy and Procedure title "Significant Change of Condition" dated 09/01/2011 included but not limited to: "Potentially life-threatening conditions require nursing assessment skills and expertise to determine whether a resident should be transferred to an acute care setting. The most appropriate transportation mode will be arranged in the event a decision is made to transfer a resident who requires health care services in an acute care setting. This decision shall be made by a licensed nurse when the resident's condition is so acute that time does not permit waiting for physician's response. -This condition change shall be put on resident's care plan with appropriate approaches to care until problem is resolved". According to Fundamentals of Nursing Lippincott Williams and Wilkins 2007 pages 65-77 stated, "A written care plan serves as a communication tool among health care team members that helps ensure continuity of care...The nursing care plan is a vital source of information about the patient's problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care...expected to review, revise and update the care plan regularly, when there are changes in condition, treatments, and with new orders..." According to Fundamentals of Nursing Lippincott Williams and Wilkins Fourth Edition page 151 stated, "Assessment involves recognizing and collecting cues, pieces of information about a client's health status. Cues may be overt (objective) or covert (subjective). Examples of overt cues are a description of an incision site or a blood pressure measurement. In the [DIAGNOSES REDACTED]." According to Fundamentals of Nursing Lippincott Williams and Wilkins Fourth Edition page 155 stated, "Only recently acknowledged as a legitimate part of nursing practice, intuition is defined as the use of insight, instinct, and clinical experience to make clinical judgments about the client. Intuition is a specialized type of knowing that triggers nursing actions and/or reflection and directly influences the nurse's ability to analyze client cues. Intuition plays a role in the nurse's ability to analyze cues rapidly, make clinical decisions, and implement nursing actions even though assessment data may be incomplete or ambiguous. Intuition comes into play when assessment data are incomplete, sketchy, or vague, or when the client looks all right on the surface but the nurse senses that something is not quite right." According to Fundamentals of Nursing Lippincott Williams and Wilkins Fourth Edition page 781 stated, "Injury Prevention-Injuries commonly cause impaired mobility, but many injuries can be prevented. The nurse can play a significant role in unintentional injury prevention: Help clients provide a safe environment for themselves and their families. Decreasing fall rates and decreasing the severity of injury for older adults are important interventions. By identifying older adults at greatest risk, the nurse can increase and individualize surveillance." On 10/19/2012 at 5:00 p.m., Nurse Consultant provided the following documentation to surveyor: 5 step for falls Failure to manage falls in timely proactive manner, timely interventions, 1. Proactive approach to interventions when necessary. 2. 30% Audit care plan to ensure accuracy. 3. In-service with the nurse by SDC (staff development coordinator) or designee: related to timely review and complete care plan and inclusion of any changes in condition. (Inservice records and staff signatures were included.) 4. 10% care plans will be monitored by DON (director of nursing) and SDC weekly x 4 weeks. Compliance will be monitored by the QA (quality assurance) committee x 3 months. 5. Date of compliance: October 16th. Physician order [REDACTED]. Accu Checks 1 finger stick every 6 hours (12:00 a.m., 6:00 a.m., 12:00 p.m., 6:00 p.m.) for diabetes mellitus. Medication Administration Record (MAR) dated 10/10/2012 documented: Accu Checks 1 every 6 hours; finger stick for diabetes mellitus. Reviewed of Resident #1's clinical record revealed documentation on the MAR for 10/11/2012 12:00 a.m., and 10/11/2012 12:00 p.m. were not available. On 10/18/2012 at 1:10 p.m., an interview was conducted with Registered Nurse-A (RN-A), Staff Development Coordinator. RN-A stated "We don't have Accu Checks for these days." On 10/18/2012 at 3:15 p.m., an interview was conducted with Licensed Practical Nurse-D (LPN-D). LPN-D stated Accu Checks were documented on the MAR. According to LPN-D if it was not documented, it was not done. On 10/18/2012 at 3:25 p.m., an interview was conducted with LPN-E. LPN-E stated Accu Checks were documented on the MAR. According to LPN-E if it was not documented, it was not done. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 09/26/2012 coded Resident #3 with ability to express ideas and wants, and the ability to understand others. In addition, the Minimum Data Set coded Resident #3 as requiring supervision during transfer; independent for dressing and eating. Physician order [REDACTED]. (liter/minute) On 10/19/2012 at 12:00 p.m., Resident #3 was in bed, observed oxygen 3 L/min. On 10/19/2012 at 12:30 p.m., Resident #3 was in bed, observed oxygen 3 L/min. On 10/19/2012 at 1:05 p.m., Resident # 3 was in bed, observed oxygen 3 L/min. On 10/19/2012 at 1:10 p.m., an interview was conducted with LPN-C. Asked LPN-C to verify Resident #3's oxygen setting. LPN-C stated "3 L/min." LPN-C then checked the POS and stated "It should be 1 L/min." On 10/19/2012 at 1:20 p.m., an interview was conducted with LPN-A. LPN-A stated Resident #3 adjusted his own oxygen level. On 10/19/2012 at 2:35 p.m., Administrator was made aware of the above findings.

Based on staff interview, facility document review, clinical record review, and in the course of complaint investigation, the facility staff failed to assess and provide an intermediate care plan for a newly admitted resident with fall risk behaviors and also failed to send the resident out for emergency services in a timely manner after a fall for 1 of 3 residents (Resident #1). Facility staff failed to send Resident #1 to the hospital in a timely manner after her fall. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Past Surgical History in 2012 included Extra-Ventricular Drainage (EVD) and Craniectomy and Dobhoff [DEVICE] placement. Facility staff was in the process of developing Resident #1's Minimum Data Set (an assessment protocol). POS (physician's orders [REDACTED]. "Physical Therapy-evaluation order physical therapy evaluate and treat." POS dated 10/10/2012, medications for Resident #1 included but not limited to: "[MEDICATION NAME] 7.5 mg (milligram) tablet 1 tab peg tube daily". Anticoagulants. Side effects included but not limited to bleeding. Nursing Implications: Assess patient for signs of bleeding and hemorrhage. Source: "Davis's Drug Guide For Nurses, Eighth Edition, pages 1067-1068". "[MEDICATION NAME] 100 mg prefilled syr (syringe) 1 ml (millilteter) sq (subcutaneous) every 12 hours". (Anticoagulants) Side effects included but not limited to bleeding. Nursing Implications: "Assess patient for signs of bleeding and hemorrhage; bleeding from surgical site. Notify physician if these occur. Source: Davis's Drug Guide For Nurses, Eighth Edition, pages 467-469". Physical Therapy Evaluation for Resident #1, dated 10/12/2012, documented: "Pt (patient) is limited with safety awareness, strength, functional ROM (range of motion), and indep (independence) with necessary functional mobility; she will benefit from PT (physical therapy) to increase indep and safety with functional mobility to prepare for safe d/c (discharge) home." Incident/Accident Report for Resident #1 documented: Date of Incident:10/15/2012 Time of Incident: 4:10 a.m. Description of Incident: Resident found on floor face down by staff-beside window. Nurse's Notes for Resident #1 dated 10/15/2012 at 04:34 a.m. documented: "Resident found on floor face down beside bed close to window by staff. Assisted back into bed by staff. Vital signs 97.0, 20, 77, 187/97. When examining resident note with swelling above right eye. Neuro checks started. ROM within normal limits. Neuro checks at baseline. Called (Facility Physician), stated to apply ice to swelling above eye and may send to ER (emergency room ) if in a lot of pain. RP (responsible party) made aware." Physician's Telephone Orders for Resident #1 dated 10/15/2012 documented: Apply ice bag to right upper forehead. May send to ER (emergency room ) if pain persist. Neurological assessment dated [DATE] at 4:10 a.m. included but not limited to: Blood Pressure (BP): 187/97 BP at 4:25 a.m.-176/91 BP at 4:40 a.m.-166/88 BP at 4:55 a.m.-173/81 BP at 5:25 a.m.-187/83 BP at 5:55 a.m.-189/87 BP at 6:25 a.m.-192/92 BP at 6:55 a.m.-230/111 On 10/18/2012 at 1:10 p.m., an interview was conducted with Registered Nurse-A (RN-A), Staff Development Coordinator. Surveyor asked Resident #1's baseline BP. RN-A stated it was 147/75, based on Resident #1's Admission Falls Risk assessment dated [DATE]. According to Fundamentals of Nursing by Ruth F. Craven & Constance J. Hirnle, Fourth Edition, pages 444, normal systolic blood pressure for adult ranges from 90-140 mm Hg, normal diastolic blood pressure for adult ranges from 60-90 mm Hg. According to the Facility Transfer Form, Resident #1 was sent to theER on [DATE] at 7:00 a.m.. ER (emergency room ) report for Resident #1 dated 10/15/2012 documented: "Diagnoses: [REDACTED]. Review of Systems Gastrointestinal: Positive for vomiting. Skin: +bruising and swelling to right forehead. Patient non-verbal at baseline. Physical Exam Hematoma right forehead with swollen right eye. Right periorbital ecchymosis. Neurological: She is unresponsive. Skin: Puncture wound right [MEDICATION NAME] with associated contusion". A hematoma, according to "Lippincott Manual of Nursing Practice, eighth edition, pg. 1149", is a "well defined pocket of blood and fluid beneath the skin". ER report for Resident #1 dated 10/15/2012 documented: "Procedure Note-Orotracheal Intubation: Indication for procedure: impending [MEDICAL CONDITION] and impending airway compromise". ER report for Resident #1 dated 10/15/2012 documented: "Progress Note-Critical Care: The reason for providing this level of medical care for this critically ill patient was due to a critical illness that impaired one or more vital organ systems (Brain) such that there was a high probability of imminent or life threatening deterioration in the patients condition. This care involved high complexity decision making to assess, manipulate, and support vital system functions, to treat this degree vital organ system failure and to prevent further life threatening deterioration of the patient's condition". On 10/17/2012 at 1:00 p.m., an interview was conducted with Licensed Practical Nurse-B (LPN-B) via phone. LPN-B was assigned to Resident #1 for the 11:00 p.m. to 7:00 a.m. shift on 10/15/2012. LPN-B stated Resident #1 was found on floor faced down at approximately 4:10 a.m., and was sent to the hospital around 7:00 a.m.. LPN-B stated Resident #1 had a hematoma above her right eye, "It's the size of a goose egg." LPN-B stated she did not send Resident #1 to the hospital immediately after her fall, because "She did not appear to be in pain." LPN-B also stated she had to pass medications to other residents that morning. Surveyor asked how Resident #1 normally communicate her needs/pain level, LPN-B stated "She doesn't, she can blink her eyes." On 10/17/2012 at 1:30 p.m., an interview was conducted with LPN-C via phone. LPN-C was assigned to Resident #1 for the 7:00 a.m. to 3:00 p.m. shift on 10/15/2012. LPN-C stated she saw Resident #1 that morning around 6:50 a.m., with a hematoma on her forehead. "It's the size of an egg." LPN-C stated Resident #1's BP was 230/111, and was vomiting. "She has to go." According to LPN-C, she instructed LPN-B to call 911. On 10/17/2012 at 3:30 p.m., an interview was conducted with Registered Nurse-A (RN-A), Staff Development. Surveyor asked to see Resident #1's care plan. RN-A stated Resident #1 should have a care plan for "Potential for Falls" due to [MEDICAL CONDITION] diagnosis. RN-A also stated "I don't see one, but she should have a Fall care plan." On 10/17/2012 at 3:40 p.m., an interview was conducted with Facility Physician. Facility Physician stated Resident #1 should be on Fall Precautions. Facility Physician stated Resident #1 had history of stroke and was on anticoagulants. On 10/17/2012 at 4:00 p.m., an interview was conducted with Nurse Consultant. Nurse Consultant stated, "We did not do a Fall care plan on her (Resident #1), we should have." On 10/17/2012 at 4:25 p.m., an interview was conducted with Certified Nurse Aid-A (CNA-A) via phone. CNA-A was the one who found Resident #1 faced down on the floor on 10/15/2012. CNA-A stated Resident #1's bed was not in the lowest position when she found Resident #1. Resident #1's bed was approximately 2 feet from the floor, according to CNA-A. CNA-A explained and demonstrated how the bed would roll; when it was put to the lowest position. CNA-A stated she was in Resident #1's room at approximately 4:00 a.m. on 10/15/2012, passing out wash cloths. CNA-A noticed Resident #1's feet were "dangling" at this time, therefore, she put Resident #1's feet back on the bed, and left the room. According to CNA-A, Resident #1 also had a "wedge" on her left side, to prevent her from rolling onto the area that was being treated. "There's a red area near her bottom." CNA-A said there were no floor mats nor alarm in place for Resident #1. CNA-A stated at approximately 4:15 a.m., when she was passing ice, she heard a "boom" sound, "very loud noise". First, CNA-A went into room [ROOM NUMBER], residents in room [ROOM NUMBER] were fine. Then CNA-A went into room [ROOM NUMBER], that's when CNA-A discovered Resident #1 on the floor faced down. CNA-A notified LPN-B of her findings. 3 staff members assisted Resident #1 back to bed. According to CNA-A, Resident #1 put her hand on forehead, "A minute later, her right eye was all swelled up, it was as big as an egg." "It gets bigger within minutes." CNA-A stated she notified LPN-B multiple times that Resident #1's BP was high, and right eye was "shut closed." "But I am just a CNA." According to CNA-A, LPN-C came in and saw Resident #1 around 6:50 a.m. and that's when LPN-C said "Send her out." On 10/18/2012 at 1:10 p.m., an interview was conducted with RN-A. RN-A stated she would send Resident #1 out immediately after the incident happened on 10/15/2012, if she was on duty, based on the fact that Resident #1's medical history. RN-A stated Resident #1 had history of [MEDICAL CONDITION], procedures done on the brain, hypertension, and currently on anticoagulants. "I would send her out immediately." On 10/18/2012 at 3:15 p.m., an interview was conducted with LPN-D. LPN-D stated Resident #1 had prior falls at home, 2 subdural hematoma and history [MEDICAL CONDITION]. "I will not wait 3 hours, I will send her out immediately." On 10/18/2012 at 3:25 p.m., an interview was conducted with LPN-E. LPN-E stated Resident #1 had history [MEDICAL CONDITION] subdural hemorrhage. "I would not wait 3 hours to send her out." LPN-E also stated Resident #1 should have floor mats and low bed. On 10/19/2012 at 11:40 a.m., an interview was conducted with RN-A, Staff Development. RN-A stated, "We are putting in place the POC (plan of correction)/care plan on Falls after you told us the issues." Facility Policy and Procedure titled "Falls" dated 10/12/2011 included but not limited to: -Communication of fall risk and interventions to direct caregiving staff -Care Plan Development with ongoing input from the Falls Interdisciplinary Committee -Assess, intervene, and promptly provide the necessary interventions for any resident experiencing a fall. -Notify the physician, responsible party, and/or EMS (emergency medical service), as well as the Supervisor/Administrative personnel as appropriate. Facility Policy and Procedure title "Significant Change of Condition" dated 09/01/2011 included but not limited to: "Potentially life-threatening conditions require nursing assessment skills and expertise to determine whether a resident should be transferred to an acute care setting. The most appropriate transportation mode will be arranged in the event a decision is made to transfer a resident who requires health care services in an acute care setting. This decision shall be made by a licensed nurse when the resident's condition is so acute that time does not permit waiting for physician's response. This condition change shall be put on resident's care plan with appropriate approaches to care until problem is resolved." According to Fundamentals of "Nursing Lippincott Williams and Wilkins 2007 pages 65-77" read, "A written care plan serves as a communication tool among health care team members that helps ensure continuity of care...The nursing care plan is a vital source of information about the patient's problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care...expected to review, revise and update the care plan regularly, when there are changes in condition, treatments, and with new orders..." According to "Fundamentals of Nursing Lippincott Williams and Wilkins Fourth Edition page 151" read, "Assessment involves recognizing and collecting cues, pieces of information about a client's health status. Cues may be overt (objective) or covert (subjective). Examples of overt cues are a description of an incision site or a blood pressure measurement. In the [DIAGNOSES REDACTED]." According to "Fundamentals of Nursing Lippincott Williams and Wilkins Fourth Edition page 155" read, "Only recently acknowledged as a legitimate part of nursing practice, intuition is defined as the use of insight, instinct, and clinical experience to make clinical judgments about the client. Intuition is a specialized type of knowing that triggers nursing actions and/or reflection and directly influences the nurse's ability to analyze client cues. Intuition plays a role in the nurse's ability to analyze cues rapidly, make clinical decisions, and implement nursing actions even though assessment data may be incomplete or ambiguous. Intuition comes into play when assessment data are incomplete, sketchy, or vague, or when the client looks all right on the surface but the nurse senses that something is not quite right." According to "Fundamentals of Nursing Lippincott Williams and Wilkins Fourth Edition page 781" read, "Injury Prevention-Injuries commonly cause impaired mobility, but many injuries can be prevented. The nurse can play a significant role in unintentional injury prevention: Help clients provide a safe environment for themselves and their families. Decreasing fall rates and decreasing the severity of injury for older adults are important interventions. By identifying older adults at greatest risk, the nurse can increase and individualize surveillance." On 10/19/2012 at 5:00 p.m., Nurse Consultant provided the following documentation to surveyor: 5 step for falls Failure to manage falls in timely proactive manner, timely interventions, 1. Proactive approach to interventions when necessary. 2. 30% Audit care plan to ensure accuracy. 3. In-service with the nurse by SDC (staff development coordinator) or designee: related to timely review and complete care plan and inclusion of any changes in condition. 4. 10% care plans will be monitored by DON (director of nursing) and SDC weekly x 4 weeks. Compliance will be monitored by the QA (quality assurance) committee x 3 months. 5. Date of compliance: October 16th. Complaint Deficiency

Based on observation, resident interview, staff interview, facility document review, clinical record review, and in the course of complaint investigation, the facility staff failed to provide a safe environment to prevent falls for 1 of 3 residents in the survey sample, Resident #1. Resident #1 sustained serious injury after a fall on 10/15/2012. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Past Surgical History in 2012 included Extra-Ventricular Drainage (EVD) and Craniectomy and Dobhoff [DEVICE] placement. Facility staff was in the process of developing Resident #1's Minimum Data Set (an assessment protocol). POS (physician's orders [REDACTED]. "Physical Therapy-evaluation order physical therapy evaluate and treat." POS dated 10/10/2012, medications for Resident #1 included but not limited to: "Coumadin 7.5 mg (milligram) tablet 1 tab peg tube daily". (Anticoagulants. Side effects included but not limited to bleeding. "Nursing Implications: Assess patient for signs of bleeding and hemorrhage". Source: "Davis's Drug Guide For Nurses, Eighth Edition, pages 1067-1068". "Lovenox 100 mg prefilled syr (syringe) 1 ml (millilteter) sq (subcutaneous) every 12 hours". Anticoagulants: Side effects included but not limited to bleeding. "Nursing Implications: Assess patient for signs of bleeding and hemorrhage; bleeding from surgical site. Notify physician if these occur". Source: "Davis's Drug Guide For Nurses, Eighth Edition, pages 467-469". Physical Therapy Evaluation for Resident #1 dated 10/12/2012 documented: "Pt (patient) is limited with safety awareness, strength, functional ROM (range of motion), and indep (independence) with necessary functional mobility; she will benefit from PT (physical therapy) to increase indep and safety with functional mobility to prepare for safe d/c (discharge) home." Incident/Accident Report for Resident #1 documented: "Date of Incident:10/15/2012 Time of Incident: 4:10 a.m. Description of Incident: Resident found on floor face down by staff-beside window." Nurse's Notes for Resident #1 dated 10/15/2012 at 04:34 a.m. documented: "Resident found on floor face down beside bed close to window by staff. Assisted back into bed by staff. Vital signs 97.0, 20, 77, 187/97. When examining resident note with swelling above right eye. Neuro checks started. ROM within normal limits. Neuro checks at baseline. Called (Facility Physician), stated to apply ice to swelling above eye and may send to ER (emergency room ) if in a lot of pain. RP (responsible party) made aware." Physician's Telephone Orders for Resident #1 dated 10/15/2012 documented: "Apply ice bag to right upper forehead. May send to ER (emergency room ) if pain persist". Neurological assessment dated [DATE] at 4:10 a.m. included but not limited to: Blood Pressure (BP): 187/97 BP at 4:25 a.m.-176/91 BP at 4:40 a.m.-166/88 BP at 4:55 a.m.-173/81 BP at 5:25 a.m.-187/83 BP at 5:55 a.m.-189/87 BP at 6:25 a.m.-192/92 BP at 6:55 a.m.-230/111 On 10/18/2012 at 1:10 p.m., an interview was conducted with Registered Nurse-A (RN-A), Staff Development Coordinator. Surveyor asked Resident #1's baseline BP. RN-A stated it was 147/75, based on Resident #1's Admission Falls Risk assessment dated [DATE]. According to "Fundamentals of Nursing by Ruth F. Craven & Constance J. Hirnle, Fourth Edition, pages 444", "normal systolic blood pressure for adult ranges from 90-140 mm Hg, normal diastolic blood pressure for adult ranges from 60-90 mm Hg". According to the Facility Transfer Form, Resident #1 was sent to theER on [DATE] at 7:00 a.m.. ER (emergency room ) report for Resident #1 dated 10/15/2012 documented: "Diagnoses: [REDACTED]. Review of Systems Gastrointestinal: Positive for vomiting. Skin: +bruising and swelling to right forehead. Patient non-verbal at baseline. Physical Exam Hematoma right forehead with swollen right eye. Right periorbital ecchymosis. Neurological: She is unresponsive. Skin: Puncture wound right subclavian with associated contusion". ER report for Resident #1 dated 10/15/2012 documented: "Procedure Note-Orotracheal Intubation: Indication for procedure: impending respiratory failure and impending airway compromise". ER report for Resident #1 dated 10/15/2012 documented: "Progress Note-Critical Care: The reason for providing this level of medical care for this critically ill patient was due to a critical illness that impaired one or more vital organ systems (Brain) such that there was a high probability of imminent or life threatening deterioration in the patients condition. This care involved high complexity decision making to assess, manipulate, and support vital system functions, to treat this degree vital organ system failure and to prevent further life threatening deterioration of the patient's condition". On 10/17/2012 at 1:00 p.m., an interview was conducted with Licensed Practical Nurse-B (LPN-B) via phone. LPN-B was assigned to Resident #1 for the 11:00 p.m. to 7:00 a.m. shift on 10/15/2012. LPN-B stated Resident #1 was found on floor faced down at approximately 4:10 a.m., and was sent to the hospital around 7:00 a.m.. LPN-B stated Resident #1 had a hematoma above her right eye, "It's the size of a goose egg." LPN-B stated she did not send Resident #1 to the hospital immediately after her fall, because "She did not appear to be in pain." LPN-B also stated she had to pass medications to other residents that morning. Surveyor asked how Resident #1 normally communicate her needs/pain level, LPN-B stated "She doesn't, she can blink her eyes." On 10/17/2012 at 1:30 p.m., an interview was conducted with LPN-C via phone. LPN-C was assigned to Resident #1 for the 7:00 a.m. to 3:00 p.m. shift on 10/15/2012. LPN-C stated she saw Resident #1 that morning around 6:50 a.m., with a hematoma on her forehead. "It's the size of an egg." LPN-C stated Resident #1's BP was 230/111, and was vomiting. "She has to go." According to LPN-C, she instructed LPN-B to call 911. On 10/17/2012 at 3:30 p.m., an interview was conducted with Registered Nurse-A (RN-A), Staff Development. Surveyor asked to see Resident #1's care plan. RN-A stated Resident #1 should have a care plan for "Potential for Falls" due to her CVA (cerebral vascular accident) diagnosis. RN-A also stated "I don't see one, but she should have a Fall care plan." On 10/17/2012 at 3:40 p.m., an interview was conducted with Facility Physician. Facility Physician stated Resident #1 should be on Fall Precautions. Facility Physician stated Resident #1 had history of stroke and was on anticoagulants. On 10/17/2012 at 4:00 p.m., an interview was conducted with Nurse Consultant. Nurse Consultant stated "We did not do a Fall care plan on her (Resident #1), we should have." On 10/17/2012 at 4:25 p.m., an interview was conducted with Certified Nurse Aid-A (CNA-A) via phone. CNA-A was the one who found Resident #1 faced down on the floor on 10/15/2012. CNA-A stated Resident #1's bed was not in the lowest position when she found Resident #1. Resident #1's bed was approximately 2 feet from the floor, according to CNA-A. CNA-A explained and demonstrated how the bed would roll; when it was put to the lowest position. CNA-A stated she was in Resident #1's room at approximately 4:00 a.m. on 10/15/2012, passing out wash cloths. CNA-A noticed Resident #1's feet were "dangling" at this time, therefore, she put Resident #1's feet back on the bed, and left the room. According to CNA-A, Resident #1 also had a "wedge" on her left side, to prevent her from rolling onto the area that was being treated. "There's a red area near her bottom." CNA-A said there were no floor mats nor alarm in place for Resident #1. CNA-A stated at approximately 4:15 a.m., when she was passing ice, she heard a "boom" sound, "very loud noise". First, CNA-A went into room #56, residents in room #56 were fine. Then CNA-A went into room #58, that's when CNA-A discovered Resident #1 on the floor faced down. CNA-A notified LPN-B of her findings. 3 staff members assisted Resident #1 back to bed. According to CNA-A, Resident #1 put her hand on forehead, "A minute later, her right eye was all swelled up, it was as big as an egg." "It gets bigger within minutes." CNA-A stated she notified LPN-B multiple times that Resident #1's BP was high, and right eye was "shut closed." "But I am just a CNA." According to CNA-A, LPN-C came in and saw Resident #1 around 6:50 a.m. and that's when LPN-C said "Send her out." On 10/18/2012 at 1:10 p.m., an interview was conducted with RN-A. RN-A stated she would send Resident #1 out immediately after the incident happened on 10/15/2012, if she was on duty, based on the fact that Resident #1's medical history. RN-A stated Resident #1 had history of strokes, procedures done on the brain, hypertension, and currently on anticoagulants. "I would send her out immediately." On 10/18/2012 at 3:15 p.m., an interview was conducted with LPN-D. LPN-D stated Resident #1 had prior falls at home, 2 subdural hematoma and history of CVA (cerebral vascular accident). "I will not wait 3 hours, I will send her out immediately." On 10/18/2012 at 3:25 p.m., an interview was conducted with LPN-E. LPN-E stated Resident #1 had history of CVA and subdural hemorrhage. "I would not wait 3 hours to send her out." LPN-E also stated Resident #1 should have floor mats and low bed. On 10/19/2012 at 11:40 a.m., an interview was conducted with RN-A, Staff Development. RN-A stated, "We are putting in place the POC (plan of correction)/care plan on Falls after you told us the issues." Facility Policy and Procedure titled "Falls" dated 10/12/2011 included but not limited to: "Communication of fall risk and interventions to direct caregiving staff -Care Plan Development with ongoing input from the Falls Interdisciplinary Committee -Assess, intervene, and promptly provide the necessary interventions for any resident experiencing a fall. -Notify the physician, responsible party, and/or EMS (emergency medical service), as well as the Supervisor/Administrative personnel as appropriate". Facility Policy and Procedure title "Significant Change of Condition" dated 09/01/2011 included but not limited to: "Potentially life-threatening conditions require nursing assessment skills and expertise to determine whether a resident should be transferred to an acute care setting. The most appropriate transportation mode will be arranged in the event a decision is made to transfer a resident who requires health care services in an acute care setting. This decision shall be made by a licensed nurse when the resident's condition is so acute that time does not permit waiting for physician's response. -This condition change shall be put on resident's care plan with appropriate approaches to care until problem is resolved". According to Fundamentals of Nursing Lippincott Williams and Wilkins 2007 pages 65-77 stated, "A written care plan serves as a communication tool among health care team members that helps ensure continuity of care...The nursing care plan is a vital source of information about the patient's problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care...expected to review, revise and update the care plan regularly, when there are changes in condition, treatments, and with new orders..." According to Fundamentals of Nursing Lippincott Williams and Wilkins Fourth Edition page 151 stated, "Assessment involves recognizing and collecting cues, pieces of information about a client's health status. Cues may be overt (objective) or covert (subjective). Examples of overt cues are a description of an incision site or a blood pressure measurement. In the [DIAGNOSES REDACTED]." According to Fundamentals of Nursing Lippincott Williams and Wilkins Fourth Edition page 155 stated, "Only recently acknowledged as a legitimate part of nursing practice, intuition is defined as the use of insight, instinct, and clinical experience to make clinical judgments about the client. Intuition is a specialized type of knowing that triggers nursing actions and/or reflection and directly influences the nurse's ability to analyze client cues. Intuition plays a role in the nurse's ability to analyze cues rapidly, make clinical decisions, and implement nursing actions even though assessment data may be incomplete or ambiguous. Intuition comes into play when assessment data are incomplete, sketchy, or vague, or when the client looks all right on the surface but the nurse senses that something is not quite right." According to Fundamentals of Nursing Lippincott Williams and Wilkins Fourth Edition page 781 stated, "Injury Prevention-Injuries commonly cause impaired mobility, but many injuries can be prevented. The nurse can play a significant role in unintentional injury prevention: Help clients provide a safe environment for themselves and their families. Decreasing fall rates and decreasing the severity of injury for older adults are important interventions. By identifying older adults at greatest risk, the nurse can increase and individualize surveillance." On 10/19/2012 at 5:00 p.m., Nurse Consultant provided the following documentation to surveyor: 5 step for falls Failure to manage falls in timely proactive manner, timely interventions, 1. Proactive approach to interventions when necessary. 2. 30% Audit care plan to ensure accuracy. 3. In-service with the nurse by SDC (staff development coordinator) or designee: related to timely review and complete care plan and inclusion of any changes in condition. (Inservice records and staff signatures were included.) 4. 10% care plans will be monitored by DON (director of nursing) and SDC weekly x 4 weeks. Compliance will be monitored by the QA (quality assurance) committee x 3 months. 5. Date of compliance: October 16th. Complaint Deficiency