Every finding on record at Hilltop Village Nursing and Rehabilitation

Based on interviews and record reviews, the facility failed to ensure the assessment accurately reflected the residents' status for 1 of 3 (Resident #1) residents in that: The facility failed to accurately code regarding Resident #1's bladder incontinence status in the resident MDS assessment. This failure could place residents at risk of inadequate care and treatment. Findings: Record review of Resident #1's face sheet, dated 08/20/2026, revealed the resident was a 78-years-old male, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnosis of urinary tract infection (an infection in any part of the urinary system, such as kidney or bladder), bradycardia (slow heart rate), and malignant neoplasm of lower lobe of right bronchus (lung cancer). Record review of Resident #1's Medicare 5-day MDS assessment, dated 08/14/2026, revealed the resident's BIMS score was 12 out of 15 which indicated the resident had moderate cognitive impairment. and the resident required Substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) to chair to bed and toilet transfer. Further record review of the MDS assessment revealed in the Section H (Bladder Bowel), it was coded that Resident #1 had an indwelling urinary catheter, but at the question of the urinary continence, it was coded to Always incontinence, instead of Not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days. Record review of Resident #1's comprehensive care plan was not updated, at that time, because the resident readmitted to the facility on [DATE] and discharged to the acute hospital on [DATE]. Record review of Resident #1's physician order, dated 08/12/2026, revealed the resident had the order of Foley catheter care (indwelling urinary catheter) and checking output every shift. In an interview on 08/20/2026 at 1:11 p.m. with the LVN-A, HE/SHE said when Resident #1 came back to the facility from an acute hospital stay on 08/12/2026, the resident had an indwelling urinary catheter, and the facility nursing staff provided catheter care to the resident. In an interview on 08/20/2026 at 1:45 p.m. with the MDS nurse LVN-B, he stated when Resident #1 came back to the facility from an acute hospital on [DATE], the resident had an indwelling urinary catheter, and it was mistake that he coded to Always incontinence, instead of Not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days in the Section H (Bladder Bowel). The MDS nurse LVN-B said he was new so sometimes he made mistakes, but he should have coded Not rated because the resident had an indwelling urinary catheter. In an interview on 08/20/2026 at 3:42 p.m. with the DON, HE/SHE said Resident #1's MDS assessment dated [DATE] was inaccurate because the resident had an indwelling urinary catheter, so it should have been coded to Not rated, instead of Always incontinence. HE/SHE stated, however, every nursing staff already knew the resident had an indwelling urinary catheter, so the inaccurate MDS assessment did not affect the resident's care, but the MDS assessment should be accurate. The DON said the facility did not have a specific policy regarding MDS assessment accuracy, but just followed MDS manual. Record review of CMS's Long-term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2025, revealed Code 9, not rated: if during the 7-day look-back period the resident had an indwelling bladder catheter, condom catheter, ostomy, or no urine output (e.g., is on chronic dialysis with no urine output) for the entire 7 days.

Based on interviews and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) out of 3 residents reviewed for administration. The LVN-C did not document accurately on Resident #1's Medication Administration Record on 08/14/2026 regarding the resident's apical pulse (heart rate). This failure could place residents at risk for missed treatments which could result in decline in healing and well-being. Findings included:Record review of Resident #1's face sheet, dated 08/20/2026, revealed the resident was a 78-years-old male, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnosis of urinary tract infection (an infection in any part of the urinary system, such as kidney or bladder), bradycardia (slow heart rate), and malignant neoplasm of lower lobe of right bronchus (lung cancer). Record review of Resident #1's Medicare 5-day MDS assessment, dated 08/14/2026, revealed the resident's BIMS score was 12 out of 15 which indicated the resident had moderate cognitive impairment and required Substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) to chair to bed and toilet transfer. Further record review of the resident MDS assessment revealed Heart Failure was coded one of Resident #1's active diagnosis in section I (Active Diagnoses). Record review of Resident #1's comprehensive care plan, dated 07/30/2026, revealed [Resident #1] has a pacemaker. For intervention - Monitor/document/report to medical doctor as needed for any signs and symptom of altered cardiac output or pacemaker malfunction: dizziness, syncope, difficulty breathing (Dyspnea), pulse rate, lower than programmed rate, lower than baseline blood pressures. Record review of Resident #1's physician order, dated 08/14/2026, revealed the resident had the order of Monitor Apical pulse Notify Medical Doctor if pulse less than 60 or greater than 100 every shift. Record review of Resident #1's Medication Administration Records from 08/01/2026 to 08/31/2026 revealed the facility nurses checked the resident's apical pulse every day at daytime and at night-time as ordered. Further record review of the resident's Medication Administration Records revealed this check was documented as N/A on 08/14/2026 at night-time by the LVN-C. In an interview on 08/20/2026 at 1:44 p.m. with the LVN-C, she said that she took care of Resident #1 on 08/14/2026 at night-time (from 6 pm to 6 am), measured the resident's apical pulse, and the apical pulse was within normal range. LVN-C said she did not know the reason she documented it as N/A on 08/14/2026 in the resident's medication administration record, and it might be her mistake. The LVN-C said she should have documented the actual number of the resident's apical pulse on the resident's medication administration record, and accurate clinical record was very important especially for Resident #1 because he had bradycardia, heart failure, and pacemaker, so the resident's care team needed to have accurate apical pulses. In an interview on 08/20/2026 at 3:42 p.m. with the DON, HE/SHE said LVN-C should have documented the actual number of Resident #1's apical pulse on the resident's medication administration record, instead of N/A. The DON stated the nurses should document accurately on Resident #1's Medication Administration Record because inaccurate medical record might provide incorrect information to the resident's primary care physician and care team. Record review of the facility's policy, titled Documentation and charting, dated July 2022, revealed It is the policy of this facility to provide nursing service personnel with a record of the physical and mental status of the resident and the elements of quality medical nursing care.

Based on observation, interview, and record review, the facility failed to ensure medication irregularities reported from the pharmacist were reported to the attending physician and the facility's medical director and director of nursing, and these reports were acted upon for 1 of 4 residents (Resident #4) reviewed for medications. The facility failed to ensure an order discrepancy for Resident #4's medication Pramipexole (a medication for a progressive neurological disorder known as Parkinson's Disease) identified by a report from the pharmacist to the facility on 6/23/2025 was resolved causing Resident #4 to receive dosing of the medication greater than intended for June, July, and August of 2025. This failure could lead to toxic ingestion or unintended side effects of residents' medications. Findings included: Record review of Resident #4's face sheet dated 8/26/2025 reflected an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included Parkinson's disease (a progressive neurological disorder that affects movement, balance, and coordination), anxiety disorder, and Alzheimer's Disease (a progressive neurological disorder affecting thinking and reasoning). Record review of Resident #4's quarterly MDS, submitted 8/13/2025, revealed a BIMS score of 14, indicating intact cognition. Section I of the MDS reflected the same diagnoses previously listed. Record review of a progress note dated 8/5/2025 written by the psychiatric NP reflected Resident #4's treatment plan included a total dose of Pramipexole 1.25mg three times a day. Record review of Resident #4's active physician orders revealed the following:Pramipexole 0.25mg tablet, give 1 tablet by mouth 3 times a day. Give with 1mg to equal 1.25mg for Parkinson's (ordered 4/10/2025)Pramipexole 1.5mg tablet, give 1 tablet by mouth 3 times a day for Parkinson's (ordered 5/22/2025)Record review of Resident #4's MAR reflected Resident #4 received both tablets of Pramipexole, totaling 1.75mg, three times a day in June, July, and August of 2025. Record review of Resident #4's medication regimen review from the consulting pharmacist reflected a recommendation dated 6/23/2025 that read as follows:Pramipexole dose - is total dose 1.75mg TID? Please review 0.25mg dose order in PCC (reads to equal 1.25mg). The document included a column titled follow-through that did not contain any additional notation next to the recommendation for Resident #4. In an interview with Resident #4 on 8/25/2025 at 1:55 PM, she reported no concerns with her medication regimen or the care provided to her by the facility. In an observation and interview on 8/26/2025 at 3:13 PM, two blister packs of medication for Resident #4 were noted to contain Pramipexole 1.5mg tabs and Pramipexole 0.25mg tabs. The instructions on the 0.25mg package reflected give with 1mg to equal 1.25mg. MA H stated Resident #4 had been receiving a total dose of 1.75mg of Pramipexole, and she could not remember if or when the dosage had been changed. She was unaware of the instructions on the order and the blister pack to give a total dose of 1.25mg. LVN I stated the order for the Pramipexole had been unchanged since April of 2025, and she was also unaware of the additional instructions to give a total dose of 1.25mg. In an interview with the DON on 8/26/2026 at 3:20 PM, she stated the order for Resident #4's Pramipexole should have reflected a total dosage of 1.75mg, and she was going to change the order. When shown the progress note from the psychiatric NP reflecting an intended dosage of 1.25mg of Pramipexole, the DON stated she would contact Resident #4's MD to clarify the order prior to changing it. She was unsure why she had not responded to the communication note dated 6/23/2025 from the pharmacist. She said she typically reviews them every month and communicates with the providers in order to correct them timely. In a subsequent interview with the DON and the MD on 8/26/2025 at 3:50 PM, they reported Resident #4's intended dosage of Pramipexole was 1.5mg total. The MD stated the medication was being managed by Resident #4's neurologist, and he had failed to discontinue the Pramipexole order for 0.25mg in May of 2025. He stated the DON and nursing staff were not at fault because they were not aware of the change in dosage that was communicated to him by the neurologist. He stated he had no clinical concerns regarding the incorrect dosage received by Resident #4 since May. The DON stated she was unsure why the recommendation from the pharmacist had not been answered when the document was received on 6/23/2025, as she reviews the recommendations monthly with the MD to ensure all recommendations are addressed. She stated the order for Resident #4's had been corrected to reflect 1.5mg three times a day. In an interview with the pharmacist on 8/27/2025 at 2:40 PM, she stated she had sent the facility documentation requesting clarification of Resident #4's dosage of Pramipexole on 6/23/2025 but had not received a response. She reported no clinical concerns from Resident #4 receiving a total dosage of 1.75mg three times a day. She stated her concern was the accuracy of the dosage. Record review of the facility policy titled Administering Medications (revised April 2019) reflected the following: 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Record review of the facility policy titled Pharmacy Services (undated) reflected the following:Facility procedures should address how and when the need for a consultation will be communicated, how the medication review will be handled if the pharmacist is off-site, how the results or report of their findings will be communicated to the physician, expectations for the physician's response and follow up, and how and where this information will be documented.

Based on observation, interview, and record review, the facility failed to ensure residents are free from unnecessary drugs for 1 of 4 (Resident #4) residents reviewed for unnecessary medications. The facility failed to ensure Resident #4 received the correct dosage of Pramipexole (a medication used to treat the neurological degenerative disorder known as Parkinson's Disease) in June, July, and August of 2025. This failure could result in accidental overdose or unintended effects of a resident's medication. Findings included: Record review of Resident #4's face sheet dated 8/26/2025 reflected an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included Parkinson's disease, anxiety disorder, and Alzheimer's Disease (a progressive neurological disorder affecting thinking and reasoning). Record review of Resident #4's quarterly MDS, submitted 8/13/2025, revealed a BIMS score of 14, indicating intact cognition. Section I of the MDS reflected the same diagnoses previously listed. Record review of Resident #4's active physician orders revealed the following:Pramipexole 0.25mg tablet, give 1 tablet by mouth 3 times a day. Give with 1mg to equal 1.25mg for Parkinson's (ordered 4/10/2025)Pramipexole 1.5mg tablet, give 1 tablet by mouth 3 times a day for Parkinson's (ordered 5/22/2025)Record review of Resident #4's MAR reflected Resident #4 received both doses of Pramipexole, totaling 1.75mg, three times a day in June, July, and August of 2025. Record review of Resident #4's medication regimen review from the consulting pharmacist reflected a recommendation dated 6/23/2025 that read as follows:Pramipexole dose - is total dose 1.75mg TID? Please review 0.25mg dose order in PCC (reads to equal 1.25mg). The document included a column titled follow-through that did not contain any additional notation next to the recommendation for Resident #4. Record review of a progress note dated 8/5/2025 written by the psychiatric NP reflected Resident #4's treatment plan included a total dose of Pramipexole 1.25mg three times a day. In an interview with Resident #4 on 8/25/2025 at 1:55 PM, she reported no concerns with her medication regimen or the care provided to her by the facility. In an observation and interview on 8/26/2025 at 3:13 PM, two blister packs of medication for Resident #4 were noted to contain Pramipexole 1.5mg tabs and Pramipexole 0.25mg tabs. The instructions on the 0.25mg package reflected give with 1mg to equal 1.25mg. MA H stated Resident #4 had been receiving a total dose of 1.75mg of Pramipexole, and she could not remember if or when the dosage had been changed. She was unaware of the instructions on the order and the blister pack to give a total dose of 1.25mg. LVN I stated the order for the Pramipexole had been unchanged since April of 2025, and she was also unaware of the additional instructions to give a total dose of 1.25mg. In an interview with the DON on 8/26/2026 at 3:20 PM, she stated the order for Resident #4's Pramipexole should have reflected a total dosage of 1.75mg, and she was going to change the order. When shown the progress note from the psychiatric NP reflecting an intended dosage of 1.25mg of Pramipexole, the DON stated she would contact Resident #4's MD to clarify the order prior to changing it. In a subsequent interview with the DON and the MD on 8/26/2025 at 3:50 PM, they reported Resident #4's intended dosage of Pramipexole was 1.5mg total. The MD stated the medication was being managed by Resident #4's neurologist, and he had failed to discontinue the Pramipexole order for 0.25mg in May of 2025. He stated the DON and nursing staff were not at fault because they were not aware of the change in dosage that was communicated to him by the neurologist. He stated he had no clinical concerns regarding the incorrect dosage received by Resident #4 since May. The DON stated she was unsure why the recommendation from the pharmacist had not been answered when the document was received on 6/23/2025, as she reviews the recommendations monthly with the MD to ensure all recommendations are addressed. She stated the order for Resident #4's had been corrected to reflect 1.5mg three times a day. In an interview with the pharmacist on 8/27/2025 at 2:40 PM, she stated she had sent the facility documentation requesting clarification of Resident #4's dosage of Pramipexole on 6/23/2025 but had not received a response. She reported no clinical concerns from Resident #4 receiving a total dosage of 1.75mg three times a day. She stated her concern was the accuracy of the dosage. Record review of the facility policy titled Administering Medications (revised April 2019) reflected the following: 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Record review of the facility policy titled Pharmacy Services (undated) reflected the following:Facility procedures should address how and when the need for a consultation will be communicated, how the medication review will be handled if the pharmacist is off-site, how the results or report of their findings will be communicated to the physician, expectations for the physician's response and follow up, and how and where this information will be documented.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to ensure 08/27/25 fruit and tossed salad had a temperature of less than 41 degrees prior to service. 2. The facility failed to ensure [NAME] G put parsley on 08/27/25 lunch with food tongs instead of using unsanitary gloves. These failures could place residents at risk for food borne illness. The findings included: Interview and observation on 08/27/25 at 11:47 AM, [NAME] F took the temperature of the tossed salad, and it was 47 degrees F. She took the temperature of the fruit, and it was 44 degrees F. [NAME] F and the kitchen staff were about to use these foods and plate the lunch trays. Interview on 08/27/25 at 11:55 AM, the CDM revealed this tossed salad and fruit were not at the proper temperatures and the kitchen staff needed to cool these foods down before meal service. She revealed these food items needed to be below 41 degrees Fahrenheit. Interview and observation on 08/27/25 at 12:06 PM revealed [NAME] G was putting parsley on residents' lunch meals with his gloved hands that he was also using to touch residents' plates and utensils on the meal tray. The CDM revealed that [NAME] G should be using tongs to put the parsley on top of residents' food Interview on 08/27/25 at 02:58 PM, the CDM revealed [NAME] G knew it was important to use tongs for parsley due to cross contamination. She revealed temperatures were very important to ensure were in recommended ranges (did not mention any other reason why). She revealed she had trained kitchen staff on proper temperatures of foods and how to properly serve food. She revealed she oversaw this, and kitchen staff knew this information already. Interview on 08/27/25 on 03:04 PM, [NAME] F (Cook G was unavailable) revealed if foods were not to temperature they would have to check the food temperature again, and then have a plan of action if they were not at the proper temperature. She revealed this was important, so they were safe to eat for the residents. She revealed they should have used tongs to touch the parsley because [NAME] G was touching everything with the same hands that he was touching the parsley. She further revealed this would help avoid cross contamination. Record Review of facility's policy Food safety, undated, reflected Hands must be washed before putting on gloves and after removing gloves as well as between tasks, between handling raw meats and ready to eat foods and between handling soiled and clean dishes, etc. Record Review of facility's policy Food temperatures, undated, reflected 2. Cold foods should be maintained at a maximum of 41 degrees F.

Based on observation, interviews, and record reviews the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 8 residents (Resident #61) observed for resident rights. The facility failed to ensure Resident #61 was allowed to eat her dinner meal on her food tray when she requested because she wanted to reduce mess in her area on the dining table. These failures could place residents at risk of not being treated with dignity and respect. Findings included:Record review of Resident #61's admission record, dated 08/27/25, reflected Resident #61 was a [AGE] year-old female initially admitted on [DATE] with diagnoses to include dementia (the loss of cognitive functioning), cognitive communication deficit, need for assistance with personal care, and lack of coordination. Record review of Resident #61's quarterly MDS assessment, dated 07/28/25, reflected Resident #61 had a BIMS score of 10 out of 15, indicating moderate cognitive impairment. It further reflected Resident #61 needed setup or clean-up assistance for eating ADL. Record review of Resident #61's care plan, last reviewed 08/17/25, reflected a focus of The resident has an ADL self-care performance deficit r/t impaired balance, initiated on 02/25/25, with interventions to include EATING: The resident is able to: feed herself with set up assist by 1 person, dated 02/25/25. Observation on 08/26/2025 at 5:35 PM revealed Resident #61 said multiple times that she wanted her dinner to remain on her dinner tray so that there would not be a mess on the table while she ate her dinner. LVN C and CNA E told Resident #61 that they would clean up after her and not to worry. Resident #61 still requested to have her dinner left on her meal tray. Interview on 08/26/2025 at 5:40 PM revealed Resident #61 wanted to leave her dinner meal on her tray because she did not want to make a mess in her area, on the dining table. Resident #45 and Resident #62 were sitting at the same table with Resident #61 and revealed they were okay that Resident #61 had her dinner meal on her tray while she ate, and that Resident #61 preferred her dinner meal stay on her tray while she ate. Interview on 08/26/25 at 05:45 PM, LVN C revealed Resident #61 wanted her dinner on her meal tray and should be able to have her food on the tray if she wanted to because it was her right. LVN C revealed Resident #61 wanted her dinner meal on her meal tray so she did not make a mess, however, they told Resident #61 they would clean up after her. Interview on 08/27/2025 01:05 PM, CNA E revealed she did take Resident #61's 08/26/25 dinner meal off her meal tray because Resident #61 said it was okay. CNA E revealed if Resident #61 wanted her dinner meal left on her meal tray to eat for dinner, she would have left it on her tray. CNA E said they will follow what residents want because it's their right to get what they request. Record review of facility's policy Resident Rights, undated, reflected 1. The resident has the right to exercise his/her rights as a resident of the facility.

Based on interviews and record reviews the facility failed to ensure residents had the right to be informed of, and participate in, their treatments, for 1 of 8 residents (Resident #107) reviewed for antipsychotic medication administration. Resident #107 was prescribed and received the antipsychotic medication Perphenazine for schizophrenia without evidence in her medical record of the state consent form 3713. The medication dose and frequency were not included in the consent form. The deficient practices could place residents at risk for side effects for which they did not consent. The findings included:Record review of Resident #107's admission record, dated 08/27/25, reflected Resident #107 was a [AGE] year-old female initially admitted on [DATE] and re-admitted [DATE] with diagnoses to include schizophrenia (mental health condition that affects how people think, feel, and behave). Record review of Resident #107's quarterly MDS assessment, dated 08/20/25, reflected Resident #107 had a BIMS score of 15 out of 15, indicating intact cognition. It further reflected Resident #107 sometimes felt lonely or isolated around others. Record review of Resident #107's Order Summary Report, dated 08/26/25, reflected Perphenazine Oral Tablet 4 MG Give 1 tablet by mouth one time a day for schizophrenia and Perphenazine Oral Tablet 4 MG Give 3 tablet by mouth at bedtime for schizophrenia Record review of Resident #107's Psychoactive Medication Consent (not the 3613 state consent form), dated 06/16/25, reflected Resident #107 consented to take Perphenazine (no dosage or frequency noted) on 06/16/25. Record review of Resident #107's care plan reflected a problem The resident is at risk for adverse reaction r/t POLYPHARMACY (simultaneous use of multiple medications), dated 08/06/25, with interventions Discuss with resident and family the number and type of medications resident is taking and the potential for drug interactions and side effects from over medication, initiated 08/05/25. Interview on 08/27/25 at 12:54 PM, ADON B revealed Psychoactive Medication Consent should be filled out prior to a resident taking a psychoactive medication and when a psychoactive medication was changed. She revealed when she started working in this facility in July was when she started auditing residents' electronic medical record to include ensuring Psychoactive Medication Consents were done and uploaded for residents. Interview on 08/27/25 at 02:20PM, the DON revealed Resident #107 started taking Perphenazine at the end of May. She revealed she was going to look for the 3613 for Perphenazine that was signed before she started taking it. Interview on 08/27/25 at 02:28 PM, DON and ADON B revealed they should have had Perphenazine 3613 signed before resident started taking this medication. The DON revealed it was important to have this form signed because sometimes residents did not want to take medications. ADON B revealed at this time, she oversaw ensuring 3613 forms were signed. Interview on 08/27/25 at 02:56 PM, Resident #107 revealed she was okay with every medication she took. She further revealed she had given consent for every medication she took and there have been no concerns about her medications. Record review of facility's policy Resident Rights, undated, reflected 26. The resident has the right to be fully informed, in advance, about the care and treatment and of any changes in the care or treatment that may affect the resident's well-being.

Based on observations, interviews, and records reviewed, the facility failed to ensure the resident environment was free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (#51) whose care was reviewed for smoking. The facility failed to provide effective monitoring and interventions to prevent Resident #51's unsupervised smoking. This deficient practice could affect resident's safety by smoking unsupervised and residents storing their smoking materials in their rooms and on their person instead of a central lock box which could lead to an unsafe smoking environment.The findings included: Review of Resident #51's face sheet dated 8/26/2025 revealed he was admitted into the facility on 1/04/2023 with diagnoses including cerebral infarction (brain stroke), ataxic gait (abnormal walking pattern), and transient cerebral ischemic attack (mini-stroke) .Review of Resident #51's quarterly MDS dated [DATE], revealed a BIMS score of 10, which indicated moderate cognitive impairment. Review of Resident #51's care plan dated 08/05/2025 revealed Resident #51 revealed resident is, a smoker with supervision and that resident is at risk for smoking related injury related to resident is a smoker he keeps buying and hiding cigarettes and lighters and will not comply with supervised smoking times.Observation on 8/25/2025 at 11:53 a.m., Resident #51 was observed smoking in the smoking area alone. Observation on 8/26/2025 at 9:47 a.m., Resident #51 was observed smoking in the smoking area alone. Interview on 8/26/2025 at 9:49 a.m., with Resident #51, resident stated he smokes when wanted due to keeping smoking paraphernalia on his person. Interview on 8/26/2025 at 1:36 pm. with LVN D regarding residents who smoke, he stated that all residents who smoke are supposed to be supervised when smoking. He stated that smoking assessments are completed by nursing either quarterly or when it is system generated. Interview on 8/26/2025 at 2:03 pm, with DON, she stated residents who smoke are supposed to be supervised. She stated smoking paraphernalia are locked and kept at the nurse's station. She stated smoking assessments are completed quarterly or when system generated, and they are completed by nursing. Interview on 8/27/2025 at 11:15 am, with Administrator, she stated all residents who smoke are supposed to be supervised. She stated that assessments are completed by nursing. She stated residents are not supposed to have any smoking paraphernalia on their person, it is supposed to be kept locked.Interview on 8/27/2025 at 5:13 pm, with CNA R, she stated smoking paraphernalia are locked and residents who smoke are supposed to be supervised. She stated there is no assigned staff member for smoke times. Interview on 8/27/2025 at 5:20 pm, with Med Aide L, she stated that smoke times are posted at the nurse's station and that residents who smoke are supposed to be supervised. She also stated that there is no assigned staff member at smoke times. Review of [NAME] Healthcare, titled Policy: Smoking - Permitted with Limitations, revealed The facility has a responsibility to oversee their use and provide supervision to maintain an accident-free environment. Furthermore, the policy stated, Matches, lighters, e-pens, etc. will not be accessible to residents that need supervision and/or assistance with smoking.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 8 residents (Resident #88) reviewed for pharmacy services. Nurse A failed to administer Resident #88's medications in a timely manner from 08/22/25 to 08/24/25 (medications to include Duloxetine HCl capsule delayed release particles 30 MG, dexamethasone Oral Tablet 4 MG, Methadone HCl Oral Tablet 10 MG, Lorazepam Oral tablet 0.5 MG, PHENobarbital Oral Tablet 15 MG). This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. Findings included:Record review of Resident #88's admission record, dated 08/26/25, reflected Resident #88 was an [AGE] year-old female admitted on [DATE] with diagnoses to include major depressive disorder. Record review of Resident #88's admission MDS assessment, dated 08/18/25, reflected Resident #88 had a BIMS score of 15 out of 15, indicating intact cognition. Record review of Resident #88's Order Summary Report, dated 08/25/25 and administered by Nurse A, reflected DULoxetine HCl capsule delayed release particles 30 MG Give 1 capsule by mouth in the morning for depression, dexamethasone Oral Tablet 4 MG give 1 tablet by mouth one time a day, Methadone HCl Oral Tablet 10 MG Give 3 tablet by mouth three times a day for pain, Lorazepam Oral tablet 0.5 MG Give 1 tablet by mouth three times a day for Anxiety, PHENobarbital Oral Tablet 15 MG Give 15 mg by mouth three times a day for Pain 1 tab TID Record review of Resident #88's Medication Admin Audit Report for 08/22/25, dated 08/26/25 and administered by Nurse A, reflected DULoxetine HCl capsule delayed release particles 30 MG Give 1 capsule by mouth in the morning for depression, dexamethasone Oral Tablet 4 MG give 1 tablet by mouth one time a day and was administered on 08/22/25 at 10:19 AM when the scheduled time was 08/22/25 at 08:00 AM. Lorazepam Oral tablet 0.5 MG Give 1 tablet by mouth three times a day for Anxiety and Methadone HCl Oral Tablet 10 MG Give 3 tablet by mouth three times a day for pain was administered on 08/22/25 at 10:18 AM when the scheduled time was 08/22/25 at 08:00 AM. PHENobarbital Oral Tablet 15 MG Give 15 mg by mouth three times a day for Pain 1 tab TID was administered on 08/22/25 at 10:17 AM when the scheduled time was 08/22/25 at 08:00 AM. Record review of Resident #88's Medication Admin Audit Report for 08/23/25, dated 08/26/25 and administered by Nurse A, reflected Lorazepam Oral tablet 0.5 MG Give 1 tablet by mouth three times a day for Anxiety, PHENobarbital Oral Tablet 15 MG Give 15 mg by mouth three times a day for Pain 1 tab TID and dexamethasone Oral Tablet 4 MG give 1 tablet by mouth one time a day and Methadone HCl Oral Tablet 10 MG Give 3 tablet by mouth three times a day for pain DULoxetine HCl capsule delayed release particles 30 MG Give 1 capsule by mouth in the morning for depression, was administered 08/23/25 at 01:32 PM when the scheduled time was 08:00 AM, Record review of Resident #88's Medication Admin Audit Report for 08/24/25, dated 08/26/25 and administered by Nurse A, reflected Lorazepam Oral tablet 0.5 MG Give 1 tablet by mouth three times a day for Anxiety, PHENobarbital Oral Tablet 15 MG Give 15 mg by mouth three times a day for Pain 1 tab TID and Methadone HCl Oral Tablet 10 MG Give 3 tablet by mouth three times a day for pain was administered on 08/24/25 at 09:48 AM when the scheduled time was 08:00 AM dexamethasone Oral Tablet 4 MG give 1 tablet by mouth one time a day was administered on 08/24/25 at 09:51 AM when the scheduled time was 08:00 AM and DULoxetine HCl capsule delayed release particles 30 MG Give 1 capsule by mouth in the morning for depression, was administered on 08/24/25 at 09:50 AM when the scheduled time was 08:00 AM Interview and observation on 08/26/25 at 8:41 AM, Resident #88 was crying and revealed she had not received her medications on time, and it affected her mental health. Interview on 08/27/25 at 02:13 PM, Nurse A revealed she thought she did work 08/22 to 08/24 and was late giving out medications but gave no reason why she administered medications late. She revealed it was important to administer on time because it is the way the doctor prescribed it and to manage pain and their health managed. Interview on 08/27/25 at 03:14 PM, the DON revealed it was important to administer medications on a timely basis because it took time for medications take effect, like pain and psychiatric medications for Resident #88. Record review of facility's policy Pharmacy Services, undated, reflected Strive to assure that medications are requested, received, and administered in a timely manner as ordered by the authorized prescriber.

Number of residents sampled: Number of residents cited: Based on observations, interviews, and record review, the facility failed to follow menus for 2 of 3 resident (Residents #24 and #76) meals reviewed for menus in that: The facility failed to follow the menu for Residents #24 and #76 for 08/25/25 lunch meal service. This failure could place residents who consume food prepared by the facility kitchen at risk of not having their nutritional needs met and/or weight loss. The findings were: Record review of Resident #24's admission record, dated 08/27/25, reflected Resident #24 was an [AGE] year-old male initially admitted on [DATE] with diagnoses to include dementia (the loss of cognitive functioning), muscle wasting and atrophy, vitamin B12 deficiency, and vitamin D deficiency. Record review of Resident #24's quarterly MDS assessment, dated 08/17/25, reflected Resident #24 had a BIMS score of 06 out of 15, indicating severe cognitive impairment. Record review of Resident #24's Order Summary Report, dated 08/27/2025, reflected a diet order of Regular diet Mechanical Soft texture, Thin consistency, with a start date of 05/20/2024. Record review of Resident #24's care plan, last reviewed 08/16/25, reflected a problem of My dietary instructions are: regular diet, mechanical soft texture, thin consistency, initiated on 04/23/24, with interventions to include Dietary to provide diet as ordered per physician Record review of Resident #24's electronic medical record reflected resident had no significant weight loss in the last 6 months. Record review of Resident #76's admission record, dated 08/27/25, reflected Resident #76 was an [AGE] year-old female initially admitted on [DATE] with diagnoses to include cognitive communication deficit, dysphagia (difficulty swallowing), and anxiety disorder. Record review of Resident #76's quarterly MDS assessment, dated 08/07/25, reflected Resident #76 had a BIMS score of 04 out of 15, indicating severe cognitive impairment. Record review of Resident #76's Order Summary Report, dated 08/27/2025, reflected a diet order of Regular diet Regular texture, Thin consistency ., with a start date of 05/16/2024. Record review of Resident #76's care plan, last reviewed 08/16/25, reflected a problem of My dietary instructions are: NAS Regular diet, regular texture, thin consistency, revised 05/29/25, with interventions to include Controlled Carbohydrate (CCHO) diet, REGULAR, THIN consistency Record review of Resident #76's electronic medical record reflected resident had no significant weight loss in the last 6 months. Record review of Week 1 menu, undated, reflected Frosted carrot cake was offered to diabetic residents and residents on a mechanical soft diet. Interview and observation on 08/25/2025 at 12:28 PM, Resident #24 awas not served carrot cake like other residents surrounding them. They revealed they wanted carrot cake and did not know why they were not served carrot cake. Resident #76 added that she also did not receive carrot cake and would like to receive carrot cake. Interview and observation on 08/25/2025 at 12:30 PM, the CDM happened to walk by and asked what was going on. She mentioned the Resident #24 could not get carrot cake because they were served a mechanical soft diet. The CDM further revealed Resident #76 could not be served carrot cake because she was on a diabetic diet. After this occurred, the CDM walked around the dining room to ensure the other residents' lunch meal included carrot cake. Interview on 08/26/25 at 6:32 PM, the CDM revealed the carrot cake was the same carrot cake that was on the menus and menus should be followed. She revealed the kitchen did not have bread pudding, which was the original dessert for today, so they had to substitute for carrot cake. She revealed substitution log was filled out and approved. The CDM revealed she originally thought these diets did not include carrot cake but realized they did include carrot cake so after meal service in the dining room, she ensured all other residents in the facility received carrot cake per their diet. Record review of facility's policy Menus, undated, reflected Menus must- be followed.

Based on observations, record reviews and interviews the facility failed to follow their own established smoking policy for 1 of 8 residents (Resident #51) reviewed for smoking in that:Resident #51 was observed smoking unsupervised in the smoking area and stating he keeps the smoking paraphernalia on his person. This deficient practice could place smoking residents at risk for injury while smoking unsupervised.The findings were: Review of Resident #51's face sheet dated 8/26/2025 revealed he was admitted into the facility on 1/04/2023 with diagnoses including cerebral infarction (brain stroke), ataxic gait (abnormal walking pattern), and transient cerebral ischemic attack (mini-stroke) .Review of Resident #51's quarterly MDS dated [DATE], revealed a BIMS score of 10, which indicated moderate cognitive impairment. Review of Resident #51's care plan dated 08/05/2025 revealed Resident #51 revealed resident is, a smoker with supervision and resident will adhere to the tobacco/smoking policies of the facility.Observation on 8/25/2025 at 11:53 a.m., Resident #51 was observed smoking in the smoking area unsupervised. Observation on 8/26/2025 at 9:47 a.m., Resident #51 was observed smoking in the smoking area unsupervised. Interview on 8/26/2025 at 9:49 a.m., with Resident #51, resident stated he smokes when he wanted due to keeping smoking paraphernalia on his person or in his room. Interview on 8/26/2025 at 1:36 pm. with LVN D regarding residents who smoke, he stated that all residents who smoke are supposed to be supervised when smoking. Interview on 8/26/2025 at 2:03 pm, with DON, she stated resident who smoke are supposed to be supervised. She stated smoking paraphernalia are locked and kept at the nurse's station. Interview on 8/27/2025 at 11:15 am, with Administrator, she stated all residents who smoke are supposed to be supervised. She stated residents are not supposed to have any smoking paraphernalia on their person, it is supposed to be kept locked.Interview on 8/27/2025 at 5:13 pm, with CNA R, she stated smoking paraphernalia are locked and residents who smoke are supposed to be supervised. She stated there is no assigned staff member for smoke times. Interview on 8/27/2025 at 5:20 pm, with Med Aide L, she stated that smoke times are posted at the nurse's station and that residents who smoke are supposed to be supervised. She also stated that there is no assigned staff member at smoke times. Review of [NAME] Healthcare, titled Policy: Smoking - Permitted with Limitations, revealed The facility has a responsibility to oversee their use and provide supervision to maintain an accident-free environment. Furthermore, the policy stated, Matches, lighters, e-pens, etc. will not be accessible to residents that need supervision and/or assistance with smoking.

Based on interview and record review the facility failed to have bedrooms that measured 80 square feet per resident in multiple bedrooms for 15 of 99 rooms (Rooms #1-5, 7-9, 12-14, 21, 27, 28, and 46) resident rooms reviewed for square footage. Based on List of measured rooms, Rooms #1-5, 7-9, 12-14, 21, 27-28 and 46 were between 72.4 and 76.4 square feet per resident per bedroom. This failure could negatively affect the quality of life for the residents living in these rooms by restricting the amount of resident care equipment and resident's personal effects that could be accommodated in these resident rooms, limiting the resident's ability to move about the room, and decreasing resident's quality of life. The findings were: During the entrance conference with the ADM on 08/25/25 at 09:18 AM, the ADM revealed they had some rooms that did not meet the required square footage. A review of Form 3762 (Room Size Waiver) signed by the Administrator on 08/26/25 revealed resident rooms 1-5, 7-9, 12-14, 21, 27, 28, and 46 were all certified rooms for two beds each and did not meet the justification criteria. Review of the undated List of Rooms meeting any one of the following: Less than the required square footage revealed rooms 1-5, 7-9, 12-14, 21, 27, 28 and 46 were listed. The measurements were as follows: room [ROOM NUMBER]: 152.8 square feet (approximately 76.4 square feet for each resident);room [ROOM NUMBER]: 149.8 square feet (approximately 74.9 square feet for each resident);room [ROOM NUMBER]: 149.2 square feet (approximately 74.6 square feet for each resident);room [ROOM NUMBER]: 148.2 square feet (approximately 74.1 square feet for each resident);room [ROOM NUMBER]: 148.2 square feet (approximately 74.1 square feet for each resident);room [ROOM NUMBER]: 148.5 square feet (approximately 74.25 square feet for each resident);room [ROOM NUMBER]: 147.9 square feet (approximately 73.95 square feet for each resident);room [ROOM NUMBER]: 148.4 square feet (approximately 74.2 square feet for each resident);room [ROOM NUMBER]: 149.2 square feet (approximately 74.6 square feet for each resident);room [ROOM NUMBER]: 149.4 square feet (approximately 74.7 square feet for each resident);room [ROOM NUMBER]: 147.1 square feet (approximately 73.55 square feet for each resident);room [ROOM NUMBER]: 144.8 square feet (approximately 72.4 square feet for each resident);room [ROOM NUMBER]: 150.2 square feet (approximately 75.1 square feet for each resident);room [ROOM NUMBER]: 145.3 square feet (approximately 72.65 square feet for each resident); androom [ROOM NUMBER]: 149.6 square feet (approximately 74.8 square feet for each resident).

Based on interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of quality of life, recognizing each resident's individuality for 1 (Resident #1) of 7 reviewed for dignity. The facility failed to ensure CNA A treated Resident #1' room, supplies and personal space with respect. This failure could place the residents at risk of feeling uncomfortable, disrespected and could decrease residents' self-esteem and/or diminished quality of life. The findings included: Record review of Resident #1's face sheet, dated 5/29/2025 revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: chronic obstructive pulmonary disease, major depressive disorder recurrent, and generalized anxiety disorder. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMs score of 15 which indicated the resident was cognitively intact with no behaviors documented. The assessment revealed Resident #1 required supervision for showering and set up assistance for dressing. Record review of Resident #1's Care Plan for ADL self-care last updated 1/31/2024 revealed the resident required supervision and set up by one staff member for showering and supervision and sept up by one staff member to dress. Record review of Resident #1's Care Plan for behavior problem last updated 5/01/2025 revealed Resident refuses to wait for assistance to shower. She has been noted to hoard towels and bed linens with interventions which included: caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by, If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner, divert attention .Monitor behavior episodes and attempt to determine underlying cause. Record review of a Form 3613-A Provider Investigation Report dated 5/21/2025 revealed Resident #1 stated in the hallway to CNA A you hit me. Resident #1 indicated she was upset the CNA (CNA A) removed a stack of towels from her room. CNA A was suspended pending investigation, a head-to-toe assessment was completed with no findings and an investigation was completed. The results of the investigation were inconclusive. During the investigation, the report indicated Resident #1 did not want CNA A fired, she just wanted her taken off the hallway. Record review of a typed statement signed by the DON and ADON, dated 5/21/2025 revealed she interviewed Resident #1 about her allegation that CNA A hit her. The document stated the resident was unable to give details regarding the incident and stated she was upset the CNA took multiple towels out of her room as resident will shower self. Resident also stated she just wants this CNA on a different hall. The resident was notified the incident was reported to the administrator and state to which she replied I don't care. I just want my towels back. Record review of a written statement documented by CNA A, dated 5/21/2025, CNA wrote she was walking down the hallway when Resident #1 stuck her arm out and bumped into her arm. She stated as she was walking away Resident #1 stated don't hit me. CNA A wrote on 5/20/2025 she took some towels out of Resident #1's room, then at smoke break the resident told CNA to go to hell. During an interview on 5/29/2025 at 2:45 p.m., CNA A stated on a Tuesday (5/20/2025) she took towels out of Resident #1's room because they were short on towels. She stated when they were short on towels, they would do a room sweep. She stated she removed a 1/2 barrel of towels or approximately 10 towels from Resident #1's room. She stated later the same day, Resident #1 looked at her and said, Go to hell. CNA A stated she did not do anything, did not respond, and just ignored it. CNA A stated on Wednesday (5/21/2025) she was just walking normal down the hall. She stated Resident #1 was passing by her. CNA A stated her hands were by her side and she was walking normal. She stated Resident #1 stuck out her arm and yelled stop hitting me. CNA A stated she felt like Resident #1 purposely bumped into her in her wheelchair. CNA A stated she told her nurse, LVN D that Resident #1 was going around telling people that she hit her. CNA A stated the DON came and got her immediately, asked her to write and statement and sent her home while they investigated. CNA A stated she did not tell the resident prior to taking the towels out of her room and did not ask for permission. She stated she knew Resident #1 was outside on a smoke break. CNA A stated she did not ask the resident because Resident #1 will go to other hallways and ask staff for towels. She stated the staff will give the towels to the resident and she just keeps stacking them up. CNA A stated she removed all of the facility towels and did not leave any of them. She stated she did leave the resident's personal towel. CNA A stated she did not want to leave any towels for Resident #1 because they do not know when the resident showers and she will go in the shower alone in her room even though they have asked her to wait for supervision. CNA A stated this was not the first time she had removed towels and felt like the resident was mostly okay with it, but something triggered her this time. CNA A stated she had been trained to know and ask if it was alright to enter and to take something. During an interview on 5/29/2025 at 3:47 p.m., Resident #1 stated she did not remember making an allegation that CNA A hit her. She stated she did not remember CNA A hitting her or making any allegation of hitting. She stated she did not like CNA A because she walked around like a buffalo. She stated CNA A was only ugly to her and only she could see it because CNA A was not like that to anyone else. Resident #1 stated she was upset with CNA A because she took her briefs, and she took towels out of her room which upset her. She stated CNA A did not ask her before she took the items. Resident #1 stated it made her feel upset because she did not know why CNA A was in her room or why she was taking her things. She stated CNA just did it and she did not know why. Resident #1 stated she never wanted to see CNA A again. She stated she had not talked to anyone at the facility about her frustration. During an interview on 5/29/2025 at 3:56 p.m., CNA A stated three days prior to taking the towels she had taken three stacks of briefs out of Resident #1s room. She stated she left one stack for Resident #1 to use. She stated she told the resident she was taking them because she needed the briefs, and she thought Resident #1 was okay with it. CNA A stated the next day Resident #1 went and asked for more which frustrated CNA A because staff gave them to her. CNA A stated Resident #1 had hoarding tendencies. She stated it was nothing new. She stated she would not let staff take anything out of her room. She stated she took the briefs and took the towels because the facility needed them. CNA A stated she had not received direction by anyone to take the items. She stated she did not tell anyone of her intention to take them. CNA A stated she had been trained in resident rights. She stated the facility was the resident's home and they had rights and that it was their belongings. CNA A stated she thought it was excessive that Resident #1 used 5-6 towels, 4 washcloths and 2 shower blankets per shower. She stated that was what Resident #1 always asked for, that was her routine but there was no reason the resident needed that many towels. CNA A stated she was not sure what the facility policy indicated she should do if the resident was not in her room. She stated Resident #1 always kept her room door shut. CNA A stated he knocked before entering but knew Resident #1 was on a smoke break and not in her room when she took the items. During an interview on 5/29/2025 at 5:26 p.m., LVN D stated on 5/21/2025 towards the end of shift at an unknown time, CNA A told her Resident #1 stated she had hit her. LVN D stated she interviewed Resident #1 said CNA A hit her three times on the arm and demonstrated with three pats to her upper arm/shoulder. LVN D stated she observed the skin and did not see any redness or marks and Resident #1 denied any pain. LVN D stated Resident #1 was not able to provide any details, including date or time the incident occurred. LVN D stated Resident #1 told the DON the same thing and again was not able to provide the date or details. LVN D stated Resident #1 does have a history of getting upset at little things. LVN D stated this was not the first time CNA A has removed towels from Resident #1's room. She stated she has also had a discussion with CNA A about the towels and showers. LVN D stated she told CNA A and other staff they cannot take the towels away, that all they could do was document when she took showers and try to educate the resident. LVN D stated she did not instruct CNA A to take briefs or towels out of Resident #1's room. She stated they cannot reuse the briefs and they have to be discarded. She stated briefs should not be taken out of a resident room. LVN D stated there was no nursing direction to the CNAs to take towels out of any rooms on that day. She stated she thinks CNA A removed the towels so Resident #1 could not shower. LVN D stated the facility has plenty of briefs and towels. She stated Resident #1 does have hoarding tendencies. She stated like she has told CNA A before, she cannot just take things out of a resident room without permission. She stated she told her staff, this was not jail, everyone has rights, residents have a right to utilize facility stuff and they are paying for services. During an interview on 5/29/2025 at 6:12 p.m., the DON stated LVN D reported to her and the Administrator that Resident #1 was accusing CNA A of hitting her. She stated she completed a head-to-toe skin assessment and there were no alterations in skin. The DON stated she asked Resident #1 what happened, and she was not able to provide any details. She stated Resident #1 did not appear to be in any distress and went at normal time to her smoke break. The DON stated after investigating the incident she believes Resident #1 was upset that CNA A took towels out of her room. She stated Resident #1 showers alone when she was not supposed to, so CNA A took the towels out of her room. The DON stated even if the resident was hoarding, staff still had to ask permission and they try would try to remove some of the items, but they still had to ask. She stated it was important because it was a resident right. She stated the staff should not remove briefs from the room because briefs cannot be used after they have been in a resident room. The DON stated the facility did not have supply issues. She stated she does not know why CNA A would remove the briefs. The DON stated staff should try to find the cause of the hoarding issues but still need to ask staff before moving the items. Record review of a facility policy titled Resident Rights, last revised December 2016 revealed; Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights included the resident's right to a. a dignified existence b. be treated with respect, kindness and dignity. e. self-determination.

Based on interview and record review, the facility failed to report all allegations of 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 to the administrator of the facility and to other officials in accordance with State law through established procedures for 1 (Resident #7) of 7 residents reviewed for reporting requirements. The DON failed to report to the Administrator and the state survey agency when Resident #7's family reported rough care and treatment. This failure could put the residents at risk of abuse and harm. The findings included: Record review of Resident #7's face sheet dated 5/29/2025 revealed a [AGE] year-old female, admitted on [DATE] and readmitted [DATE] with diagnoses which included: noninfective gastroenteritis and colitis (inflammation of the stomach and colon), generalized muscle weakness and urge incontinence. Record review of Resident #7's modification of 5-day admission MDS assessment dated [DATE] revealed a BIMs score of 15 which indicated the resident was cognitively intact. The assessment indicated Resident #7 required maximum assistance with transfers. Record review of Resident #7's Care Plan for ADL self-care last revised on 5/28/2025 revealed the resident required the assistance of one staff member for toileting and transfers. Record review of TULIP on 5/28/2025 revealed there were no facility self-reported incidents for Resident #7. During an interview on 5/29/2025 at 1:25 p.m. with Resident #7 and family, Resident #7 appeared confused to short term memory recall. She was unable to accurately recall what she had for lunch that day. She stated staff checked on her several times during the day and at night and she felt safe in the building with no current concerns. Resident #7's family members #1 and #2 stated they had concerns about CNA B (an agency staff member). Family member #2 stated CNA B sometime last week on an unknown date during the daytime shift assisted Resident #7 to the bathroom. Family member #2 stated the family stepped out into the hallway to give Resident #7 some privacy while the staff took the resident to the toilet. She stated when she was finished toileting Resident #7's face was beat red, she was upset and stated CNA B pushed her down onto the toilet. Family member #2 stated they could tell and felt like something had occurred because Resident #7 was upset. She stated Resident #7 was unable to say exactly what had occurred. Family member #2 stated she went and found a staff member (CNA E). Family member #2 stated CNA E came into the room, got down on Resident #7's level and asked what happened. Family member #2 stated Resident #7 told CNA E exactly she had received rough care. Family member #2 stated the next day they came back to the facility and were surprised to see CNA B at work. She stated this time she went straight to the DON who was in her office and told her what occurred. Family member #2 stated she told them the same thing she had reported today. The family member stated since that date last week, they had not seen CNA B in the facility. During an interview on 5/29/2025 at 2:25 p.m., CNA E who identified herself as the facility scheduler, stated on an unknown date, last week on day shift, Resident #7's family had approached her and stated agency CNA B had taken Resident #7 to the bathroom. They stated there was a gait belt in the room but CNA B stated she did not use one and they stepped out. CNA E stated the family said when they went back in the resident had stated CNA B was very rough with her. CNA E stated she asked Resident #7 what had happened. She stated she was rough with her when she wiped her. CNA E stated she did not say anything else just that she was rough when she wiped. CNA E stated the family reported CNA B told them if they were in the room, they should be helping the resident instead of her. CNA E stated she immediately informed the DON who send CNA B home. CNA E stated they had not had CNA B back at the facility since she was sent home. CNA E stated she had completed abuse training. She stated she knew she had to report abuse to the Administrator immediately. She stated abuse was any harm to the resident. She stated she considered rough care as abuse. CNA B stated she did not tell the Administrator directly. She stated she did not tell the Administrator because the DON told the Administrator. CNA B stated she was instructed by the DON, as the scheduler, she was not to allow CNA back in the building again, so she removed her from the schedule. CNA E stated she did not see any injuries on the resident, but it was the nurses responsibility to do an assessment. She stated Resident #7 was not crying, but she was upset. During an interview on 5/29/2025 at 3:09 p.m., CNA E stated she wanted to correct a mistake on the previous interview. She stated CNA B was not sent home that day. She was allowed to continue to work but she was told to stay away from Resident #7 and she could not go back in the resident rooms. CNA E stated it was the following day, when the family saw CNA E in the building that the DON told her not to allow CNA B back in the building. During an interview on 5/29/2025 at 6:23 p.m., the DON stated Resident #7's family was upset CNA B refused to use a gait belt and was rude. The DON stated rude meant she said no to the gait belt. The DON stated she told CNA E that CNA B could not be assigned to Resident #7. The DON stated the next day, date unknown, the family approached her and asked why CNA B was back in the building and they were very upset. The DON stated she told the family she would take care of it and that CNA B was not assigned to Resident #7. The DON stated she told CNA E to send CNA B home and the facility had not utilized her again because Resident #7 was very upset. The DON stated there were no reports of abuse. She stated it was only reported to her that the family was upset that she did not use a gait belt. She stated she did not talk to the resident directly and did not report to the Administrator because there was no abuse. The DON stated she needed to review her notes and left the interview. During an interview on 5/29/2025 at 7:28 p.m., the DON stated CNA E reported to her that Resident #7 was not in any distress. The DON stated it was only reported to her that CNA B was rude and there were no indications of abuse. The DON stated Resident #7 was calm and asleep and she did not speak to her because CNA E had spoken to the resident. The DON stated CNA B did not give her any more specifics. The DON stated she sent CNA B home the next day, because the family was upset and because of her work ethic of not using a gait belt. The DON stated she did not need to report abuse because the family had reported rudeness. She stated she also did not report to the Administrator because again, the family had only reported rudeness and an issue with a gait belt. She stated there were no specifics like yelling, talking back or anything that indicated abuse. During an interview on 5/30/2025 at 8:02 a.m. agency CNA B stated on 5/23/2025 was the date the bathroom situation occurred and 5/24/2025 was the day she was sent home. CNA B stated on 5/23/2025 Resident #7 call light was going off and two people in the room (family) told her the resident needed to go to the bathroom. CNA B stated after the resident finished on the toilet, she was helping the resident transfer from the commode to the wheelchair and the resident's foot got stuck and her knee locked. CNA B stated she told Resident #7 to hold onto the rail. She stated she grabbed Resident #7 by the pants, pulled her up by her pants and helped her to pivot to the wheelchair. CNA B stated Resident #1 got upset and asked why she had stretched her pants. CNA B stated the family complained that she was too rough. She denied abusing the resident or being rough with care. During an interview on 6/02/2025 at 9:22 a.m., the Administrator stated after surveyor intervention on 5/29/2025 she called the Resident #7's family about their concerns. She stated Resident #7's family expressed concerns about CNA B. She stated they said CNA B did not seem self-assured with the use of the gait belt. The Administrator stated after the family went back into the room after the toileting, they reported that CNA B told them the next time the resident needed help, they could help her. The Administrator also reported the agency staff wiped the resident hard per Resident #7. She stated 5/29/2025 was the first time she had heard of the incident when surveyor started asking questions. She stated no one had reported it to her prior to this date. The Administrator stated the DON had responded by removing CNA B from caring for the resident. The Administrator stated CNA E got involved because she was the scheduler and the family originally told CNA E. She stated CNA E then told the DON and the DON responded by removing her from the care of the resident. The Administrator stated since learning of the incident on 5/29/2025 she knows CNA E did not report the incident to her, she reported to the DON. She stated the DON indicated CNA E told her CNA B was very rude, mentioned the gait belt and said she was wiped hard. The Administrator stated the DON strictly recalled the RP saying CNA B was rude but does not recall anything else except being upset about the gait belt. The Administrator stated she did not know what she expected the DON to do. She stated that would have depended on what the DON was told. The Administrator stated she thought the DON handled it appropriately and would not have expected it to be reported based on what she was told. The Administrator stated rudeness was a common complaint made of agency staff. She stated to distinguish rudeness from abuse was based on mental anguish. She stated when they hired agency, they did not know their work ethic. She stated agency staff come with an attitude, but it does not mean it crossed the line into abusiveness. The Administrator stated they did have an abuse policy in place which does require reporting. She stated the staff received abuse training upon hire and annually. She stated they do abuse in-services as issues arise that are specific to the issue at hand. She stated there are keywords such as hard, rough, pain that should be investigated and reported. She stated rough care should be looked at but she could not say if it was or was not abuse. She stated agency staff, such as CNA B did receive abuse training before she was allowed to work on the floor. Record review of a facility policy, titled Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating last revised September 2022 revealed: All reports of abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Finding of all investigations are documented and reported. and If resident abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown origin is suspected, the suspiciaion must be reported immediately to administrator and other officials in accordance with State law.

Based on interviews, and record reviews the facility failed to have evidence all allegations of abuse, neglect or mistreatment were thoroughly investigated and documented for 1 of 9 residents (Resident #7) reviewed for abuse. The facility failed to ensure an allegation of rough care and treatment was investigated and the DON's notes/documentation were retained regarding Resident #7 family complaints of rough care and treatment. These failures could place residents as risk for abuse and neglect by not investigating allegations of abuse, neglect, exploitation, or mistreatment. The findings included: Record review of Resident #7's face sheet dated 5/29/2025 revealed a [AGE] year-old female, admitted on [DATE] and readmitted [DATE] with diagnoses which included: noninfective gastroenteritis and colitis (inflammation of the stomach and colon), generalized muscle weakness and urge incontinence. Record review of Resident #7's modification of 5-day admission MDS assessment dated [DATE] revealed a BIMs score of 15 which indicated the resident was cognitively intact. The assessment indicated Resident #7 required maximum assistance with transfers. Record review of Resident #7's Care Plan for ADL self-care last revised on 5/28/2025 revealed the resident required the assistance of one staff member for toileting and transfers. Record review of facility grievances for May 2025 revealed no grievances were documented regarding Resident #7. During an interview on 5/29/2025 at 1:25 p.m. with Resident #7 and her family members, Resident #7 appeared confused to short term memory recall. She was unable to accurately recall what she had for lunch that day. She stated staff checked on her several times during the day and at night and she felt safe in the building with no current concerns. Resident #7's family members #1 and #2 stated they had concerns about an CNA B (an agency staff member). Family member #2 stated CNA B sometime last week on an unknown date during the daytime shift assisted Resident #7 to the bathroom. Family member #2 stated the family stepped out into the hallway to give Resident #7 some privacy while the staff took the resident to the toilet. She stated when she was finished toileting Resident #7's face was beat red, she was upset and stated CNA B pushed her down onto the toilet. Family member #2 stated they could tell and felt like something had occurred because Resident #7 was upset. She stated Resident #7 was unable to say exactly what had occurred. Family member #2 stated she went and found a staff member (CNA E). Family member #2 stated CNA E came into the room, got down on Resident #7's level and asked what happened. The family member stated the Resident told CNA E she had received rough care. Family member #2 stated the next day they came back to the facility and were surprised to see CNA B at work. She stated this time she went straight to the DON who was in her office and told her what occurred. Family member #2 stated she told them the same thing she had reported today. Family member #2 stated since that date last week, they had not seen CNA B in the facility. During an interview on 5/29/2025 at 2:25 p.m., CNA E who identified herself as the facility scheduler, stated on an unknown date, last week on day shift, Resident #7's family had approached her and stated agency CNA B had taken Resident #7 to the bathroom. They stated there was a gait belt in the room but CNA B stated she did not use one and they stepped out. CNA E stated the family said when they went back in the resident had stated CNA B was very rough with her. CNA E stated she asked Resident #7 what had happened. She stated she was rough with her when she wiped her. CNA E stated she did not say anything else just that she was rough when she wiped. CNA E stated the family reported CNA B told them if they were in the room, they should be helping the resident instead of her. CNA E stated she immediately informed the DON who send CNA B home. CNA E stated they had not had CNA B back at the facility since she was sent home. CNA E stated she had completed abuse training. She stated she knew she had to report abuse to the Administrator immediately. She stated abuse was any harm to the resident. She stated she considered rough care as abuse. CNA B stated she did not tell the Administrator directly. She stated she did not tell the Administrator because the DON told the Administrator. CNA B stated she was instructed by the DON, as the scheduler, she was not to allow CNA back in the building again, so she removed her from the schedule. CNA E stated she did not see any injuries on the resident, but it was the nurses responsibility to do an assessment. She stated Resident #7 was not crying, but she was upset. During an interview on 5/29/2025 at 3:09 p.m., CNA E stated she wanted to correct a mistake on the previous interview. She stated CNA B was not sent home that day. She was allowed to continue to work but she was told to stay away from Resident #7 and she could not go back in the resident rooms. CNA E stated it was the following day, when the family saw CNA E in the building that the DON told her not to allow CNA B back in the building. During an interview on 5/29/2025 at 6:23 p.m., the DON stated Resident #7's family was upset CNA B refused to use a gait belt and was rude. The DON stated rude meant she said no to the gait belt. The DON stated there were no reports of abuse. She stated it was only reported to her that the family was upset that she did not use a gait belt. The DON stated she thought they had done a skin assessment on the resident by a charge nurse but was unable to find it. She stated she was unable to find her notes from the incident after looking through her notes and binders. The DON stated she already shredded the documents. She stated she did not talk to the resident directly and did not report to the Administrator because there was no abuse. The DON stated she needed to review her notes and left the interview. During an interview on 5/29/2025 at 7:28 p.m., the DON stated CNA E reported to her that Resident #7 was not in any distress. The DON stated it was only reported to her that CNA B was rude and there were no indications of abuse. The DON stated Resident #7 was calm and asleep and she did not speak to her because CNA E had spoken to the resident. The DON stated CNA B did not give her any more specifics. The DON stated she sent CNA B home the next day, because the family was upset and because of her work ethic of not using a gait belt. The DON stated she did not investigate the incident because CNA E was the person dealing with the family and CNA B. She stated there was no indication of abuse. She stated she did not interview CNA B or the resident. During an interview on 5/30/2025 at 8:02 a.m. agency CNA B stated on 5/23/2025 was the date the bathroom situation occurred and 5/24/2025 was the day she was sent home. CNA B stated on 5/23/2025 Resident #7 call light was going off and two people in the room (family) told her the resident needed to go to the bathroom. CNA B stated after the resident finished on the toilet, she was helping the resident transfer from the commode to the wheelchair and the resident's foot got stuck and her knee locked. CNA B stated she told Resident #7 to hold onto the rail. She stated she grabbed Resident #7 by the pants, pulled her up by her pants and helped her to pivot to the wheelchair. CNA B stated Resident #1 got upset and asked why she had stretched her pants. CNA B stated the family complained that she was too rough. She denied abusing the resident or being rough with care. During an interview on 6/02/2025 at 9:22 a.m., the Administrator on 5/29/2025 was the first time she had heard of the incident when surveyor started asking questions. She stated no one had reported it to her prior to this date and an investigation was started on 5/29/2025 after surveyor intervention. She stated after surveyor intervention on 5/29/2025 she called the Resident #7's family about their concerns. She stated Resident #7's family expressed concerns about CNA B. She stated they said CNA B did not seem self-assured with the use of the gait belt. The Administrator stated after the family went back into the room after the toileting, they reported that CNA B told them the next time the resident needed help, they could help her. The Administrator also reported the agency staff wiped the resident hard per Resident #7. The Administrator stated the DON had responded by removing CNA B from caring for the resident. The Administrator stated CNA E got involved because she was the scheduler and the family originally told CNA E. She stated CNA E then told the DON and the DON responded by removing her from the care of the resident. The Administrator stated since learning of the incident on 5/29/2025 she knows CNA E did not report the incident to her, she reported to the DON. She stated the DON indicated CNA E told her CNA B was very rude, mentioned the gait belt and said she was wiped hard. The Administrator stated the DON strictly recalled the RP saying CNA B was rude but does not recall anything else except being upset about the gait belt. The Administrator stated she did not know what she expected the DON to do. She stated that would have depended on what the DON was told. The Administrator stated she thought the DON handled it appropriately and would not have expected it to be reported based on what she was told. The Administrator stated rudeness was a common complaint made of agency staff. She stated to distinguish rudeness from abuse was based on mental anguish. She stated when they hired agency, they did not know their work ethic. She stated agency staff come with an attitude, but it does not mean it crossed the line into abusiveness. The Administrator stated they did have an abuse policy in place which does require a thorough investigation. She stated the staff received abuse training upon hire and annually. She stated they do abuse in-services as issues arise that are specific to the issue at hand. She stated there are keywords such as hard, rough, pain that should be investigated and reported. She stated rough care should be looked at, but she could not say if it was or was not abuse. She stated agency staff, such as CNA B did receive abuse training before she was allowed to work on the floor. Record review of a facility policy, titled Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating last revised September 2022 revealed: All reports of abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Finding of all investigations are documented and reported.

Based on interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 resident (Resident # 7) reviewed for activities of daily living. The facility failed to ensure CNA B utilized a gait belt to transfer Resident #7 while toileting. This failure could place residents at risk for falls, injury and a diminished quality of life. The findings include: Record review of Resident #7's face sheet dated 5/29/2025 revealed a [AGE] year-old female, admitted on [DATE] and readmitted [DATE] with diagnoses which included: noninfective gastroenteritis and colitis (inflammation of the stomach and colon), generalized muscle weakness and urge incontinence. Record review of Resident #7's modification of 5-day admission MDS assessment dated [DATE] revealed a BIMs score of 15 which indicated the resident was cognitively intact. The assessment indicated Resident #7 required maximum assistance with transfers. Record review of Resident #7's Care Plan for ADL self-care last revised on 5/28/2025 revealed the resident required the assistance of one staff member for toileting and transfers. Prior to the revision, her care plan said the same. During an interview on 5/29/2025 at 1:25 p.m. with Resident #7 and her family members, Resident #7 appeared confused to short term memory recall. She was unable to accurately recall what she had for lunch that day. She stated staff checked on her several times during the day and at night and she felt safe in the building with no current concerns. Resident #7's family members #1 and #2 stated they had concerns about CNA B (an agency staff member) who refused to use a gait belt for a transfer. Family member #2 stated agency CNA B sometime last week on an unknown date during the daytime shift assisted Resident #7 to the bathroom. Family member #2 stated the family stepped out into the hallway to give Resident #7 some privacy while the staff took the resident to the toilet. She stated when she was finished toileting Resident #7's face was beet red, she was upset and stated CNA B pushed her down onto the toilet. Family member #2 stated they could tell and felt like something had occurred because Resident #7 was upset. She stated Resident #7 was unable to say exactly what had occurred. During an interview on 5/29/2025 at 2:25 p.m., CNA E who identified herself as the facility scheduler, stated on an unknown date, last week on day shift, Resident #7's family had approached her and stated agency CNA B had taken Resident #7 to the bathroom. They stated there was a gait belt in the room, but CNA B stated she did not use one and they stepped out. CNA E stated the family said when they went back in the resident had stated CNA B was very rough with her. CNA E stated she asked Resident #7 what had happened. She stated she was rough with her when she wiped her. CNA E stated she did not say anything else just that she was rough when she wiped. CNA E stated the family reported CNA B told them if they were in the room, they should be helping the resident instead of her. During an interview on 5/29/2025 at 6:23 p.m., the DON stated CNA E reported to her the family was upset because CNA B refused a gait belt and was rude. She stated she informed CNA B the family was upset that she did not use a gait belt and was rude. The DON stated CNA B responded by saying it was not necessary to use a gait belt for a one person assist who was able to stand for the commode. The DON stated she told CNA B she should have used a gait belt. During an interview on 5/29/2025 at 7:28 p.m., the DON stated Resident #7 did not have any injuries as a result. The DON stated she told CNA E not to utilize CNA B on the schedule any longer. She stated since the family made a complaint about her refusing to use a gait belt, they just decided not to use her as agency. The DON stated the did not know the agency staff work ethic until they were in the building. She stated some are good and some are bad, and they try to weed out the bad ones. She stated she did not do any training because they just were not going to use any agency person without a good work ethic. The DON stated a gait belt should be utilized for transfers for safety. During an interview on 5/30/2025 at 8:02 a.m. CNA B (agency staff) stated 5/23/2025 was the date the bathroom situation occurred and 5/24/2025 was the day she was sent home. CNA B stated on 5/23/2025 Resident #7 call light was going off and two people in the room (family) told her the resident needed to go to the bathroom. CNA B stated after the resident finished on the toilet, she was helping the resident transfer from the commode to the wheelchair and the resident's foot got stuck and her knee locked. CNA B stated she told Resident #7 to hold onto the rail. She stated she grabbed Resident #7 by the pants, pulled her up by her pants and helped her to pivot to the wheelchair. CNA B stated Resident #1 got upset and asked why she had stretched her pants. CNA B stated the family complained that she was too rough. CNA B stated she was not going to let the lady fall. She stated it was tight quarters and she pulled the pants with the belt loop to get her up and to pivot. She stated she never saw a gait belt in the facility when she worked there and she never asked for one. She denied that the family asked her to use one. She stated they just asked her to assist her to the toilet. CNA B stated Resident #7 leaned forward in her chair and assisted with the transfer. She stated for the transfer from the recliner to the bathroom she put her hand under Resident #7's arm and assisted her to a standing position while the resident did most of the work. She stated it was from the commode to the wheelchair where she got in trouble. She stated she was trained to use a gait belt to do one person transfers. During an interview on 6/02/2025 at 1:41 pm the DON stated they did not have a policy for one person transfers or gait belt transfers.

Based on observations, interviews, and record reviews, the facility failed to ensure residents' right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate for 4 of 4 residents (Residents #2-5) reviewed for medication self-administration. 1. The facility failed to assess Residents #2-5 for medication self-administration and ensure the medications were being administered per the physician's order. 2. The facility failed to implement care planning for Residents #2-5 for medication self-administration. These failures put residents at risk for incorrect medication administration, which could lead to unintended medication side effects, ineffective therapeutic effects of medications, or illness. In an interview with the DON on 4/17/2025 at 09:13 AM, the DON reported that 4 total residents at the facility have physician orders to self-administer medications. The DON provided the names of the four residents (Residents #2-5). Record review of the residents' electronic medical records revealed the following: Resident #2's face sheet dated 4/15/2025 reflected an [AGE] year-old male with an initial admitted [DATE]. Relevant diagnoses included occipital neuralgia (severe pain in the back of the head and neck) and idiopathic peripheral autonomic neuropathy (chronic nerve pain and/or numbness). Resident #2's quarterly MDS submitted on 4/1/2025 reflected a BIMS score of 13, indicating intact cognition. Active physician orders for the resident included: a. Fluticasone propionate nasal suspension 50mcg/act, 1 spray in both nostrils in the morning for allergies unsupervised self-administration (order dated 12/13/2024) b. Lidocaine HCl external cream 4%, apply to ble topically at bedtime for neuropathy pain unsupervised self-administration (order dated 12/13/2024) c. Systane complete ophthalmic solution, instill 1 drop in both eyes every 4 hours as needed for dry eyes unsupervised self-administration (order dated 12/13/2024) d. Diclofenac sodium external gel 1%, apply to knees, ankles, feet topically every 6 hours for pain- mild; pain [sic] unsupervised self-administration apply 4 grams (order dated 12/7/2024) Resident #2's comprehensive care plan, printed 4/15/2025, did not include any focus areas or interventions related to self-administration of medication. Documentation of care plan meetings hosted on 2/25/2025, 11/26/2024, and 8/27/2024 did not contain documentation of self-administration of medication being discussed by the interdisciplinary team. An assessment in the electronic medical record titled Self Administration of Medication was documented on 4/17/2025. The documented assessment indicated that the resident was approved for self-administration of medications and may keep meds at bedside. No additional assessments addressing self-administration of medication were located within the record. On 4/15/2025 at 1:48 PM, Resident #2 was observed storing 5 medications in a dresser drawer without a lock in his room. The medications contained within the drawer were observed, and it was noted that the resident had possession of 2 medications that did not have physician's orders for self-administration. These medications were Hydrophilic top cream prescription cream and lidocaine ointment 5%. The resident was interviewed during the observation, and he reported having difficulty self-administering the diclofenac sodium external gel 1% to his upper back. It was noted during record review that the physician's order for this medication indicated that the gel be applied to the resident's knees, ankles, and feet; not his back. Resident #3's facesheet dated 4/17/2025 reflected a [AGE] year-old-male with readmitted [DATE]. Relevant diagnoses included repeated falls, other abnormalities of gait and mobility, and unspecified asthma (a breathing disorder that causes constriction of the airway and inhibits breathing). Resident #2's annual MDS submitted 1/30/2025 reflected a BIMS score of 15, indicating intact cognition. Active physician orders for the resident included: a. Trelegy ellipta inhalation aerosol powder breath activated 200-62.5mcg/act, 1 puff inhale orally one time a day for asthma unsupervised self-administration. Rinse mouth after use (order dated 4/16/2025) No assessments addressing self-administration of medication were located within the electronic medical record of Resident #3. The comprehensive care plan, printed 4/17/2025, did not include any focus areas or interventions related to self-administration of medication. Documentation of an interdisciplinary care plan meeting hosted on 2/27/2025 reflected discussion between the team about self-administration of medications and indicated that resident was safe to self-administer. Resident #3 was observed on 4/17/2025 at 1:55 PM, the resident was interviewed and asked if observation could made of any medications that he self-administered. The resident removed a container of over-the-counter lubricant eye drops from the nightstand drawer that did not have a lock. The resident reported no other medications stored in his room, which was inconsistent with the physician's orders. The resident did not have an active prescription from the facility physician for the eye drops, and the Trelegy Ellipta was not observed in the drawer. The resident reported that he last used the eye drops not even every day. The resident stated he did not know what symptoms prompt the use of the eye drops. Resident #4's facesheet dated 4/17/2025 reflected an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included unspecified asthma and unspecified glaucoma (damage to the nerves of the eye causing vision loss). The annual MDS submitted on 3/25/2025 reported a BIMS score of 15, indicated intact cognition. Active physician orders for the resident included: a. Fluticasone-salmeterol aerosol powder breath active 100-50mcg/dose, 1 inhalation inhale orally every 12 hours for SOB [shortness of breath] unsupervised self-administration. Rinse mouth after use (order dated 8/31/2024) b. Latanoprost solution 0.005%, instill 1 drop in both eyes at bedtime unsupervised self-administration (order dated 8/28/2024) c. Propylene glycol-glycerin ophthalmic solution 1-0.3%, instill 1 drop in both eyes one time a day for dry eyes unsupervised self-administration (order dated 8/28/2024) d. Timoptic ophthalmic solution 0.5%, instill 1 drop in both eyes two times a day for glaucoma unsupervised self-administration (order dated 8/29/2024) Resident #4's electronic medical record contained self-administration medication assessments documented on 1/8/2018 and 5/28/2018. No additional assessments were located within the record. Documentation of interdisciplinary care plan meetings on 2/27/2025, 11/26/2024, and 8/29/2024 did not contain documentation of discussion regarding self-administration of medication. Resident #4's comprehensive care plan, date printed 4/17/2025 did not contain focus areas or interventions related to self-administration of medication. Resident #4 was observed storing the 4 previously listed medications on the top surface of the nightstand on 4/17/2025 at 1:45 PM. Interview with the resident during the observation did not reveal any discrepancies between the ordered medications and resident's description of self-administration. Resident #5's facesheet dated 4/17/2025 reflected a [AGE] year-old female initially admitted to the facility on [DATE]. Relevant diagnoses included other seasonal allergic rhinitis (seasonal allergies causing runny nose), absolute glaucoma, bilateral (vision loss in both eyes from nerve damage), and reduced mobility. Active physician orders for the resident included: a. Artificial tears ophthalmic solution 0.2-0.2-1%, instill 1 drop in both eyes every 4 hours as needed for dry itchy eyes unsupervised self-administration (order dated 8/29/2023) b. Artificial tears ophthalmic solution 0.2-0.2-1%, instill 1 drop in both eyes every 2 times a day for dry itchy eyes unsupervised self-administration (order dated 8/29/2023) c. Biofreeze external gel 4% (menthol topical analgesic), apply to affected areas topically every 6 hours as needed for joint pain unsupervised self-administration (order dated 6/08/2023) d. Biofreeze Professional external gel 5% (menthol topical analgesic), apply to bilateral ankle topically every 4 hours as needed for pain can keep at bedside (order dated 8/30/2024) e. Blink tears ophthalmic gel 0.25%, instill 1 drop in both eyes two times a day for dry eyes unsupervised self-administration (order dated 8/15/2023) f. Voltaren arthritis pain external gel 1%, apply to bil [bilateral] knees and shoulders topically every 6 hours as needed for pain . unsupervised self-administration 4GMs to joints NTE [not to exceed] 32 GMs in 24 hours (order dated 6/09/2023) Resident #5's comprehensive care plan, date printed 4/17/2025 did not contain focus areas or interventions related to self-administration of medication. Documentation of interdisciplinary care plan meetings hosted on 3/11/2025, 12/12/2024, and 9/5/2024 do not contain documentation of medication self-administration discussion. Resident #5 was observed storing 2 eye drop medications on top of the bedside table next to the bed on 4/16/2025 at 8:37 AM. An interview conducted at this time did not reveal any inconsistencies with the physician's orders. During routine medication administration observation of MA H on 4/16/2025, Resident #5 was observed receiving scheduled medication at 8:37 AM. MA H was not observed verifying with Resident #5 if medications ordered for self-administered had been administered. An interview was conducted with LVN A on 4/16/2025 at 10:07 AM. LVN A explained there is nothing to document on the MAR for self-administered medications, the order will simply populate as a reminder that the medication is due. LVN A stated her responsibility is to ensure the resident has the ordered medication and to reorder as necessary, but she does not verify administration. The DON was interviewed on 4/17/2025 at 9:13 AM. She reported that determination of safety for self-administration of medications by residents is made during quarterly care plan meetings and by assessment from the primary nursing staff, and residents must show that they are able to recite the medication frequency and dosage as well as physically able to ingest the medication, such as an inhaler.The DON said that during routine medication administration, the nursing staff should be verifying at that time that the resident self-administered the ordered medications. The DON was unaware that nursing staff were not verifying the self-administered medications. The DON was also unaware that residents with orders to self-administer medications did not have correct medications stored in their rooms. The DON stated care plans should include planning for self-administration of medications. Record review of policy titled Administering Medications (revised April 2019). Self-administration of medication is addressed in item #27 and reflected residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.

Based on observations, interviews, and record reviews, the facility failed to store all drugs in locked compartments for 4 of 4 residents (Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for self-administration of medications. The facility failed to ensure that residents (Residents #2-5) with physician orders to self-administer medications had methods of securing medications that prevented other residents from having access. This failure could lead to unintended access and ingestion of medication causing illness. Findings included: In an interview with the DON on 4/17/2025 at 09:13 AM, the DON reported that 4 total residents at the facility have physician orders to self-administer medications. The DON provided the names of the four residents (Residents #2-5). Record review of the residents' electronic medical records revealed the following: Resident #2's face sheet dated 4/15/2025 reflected an [AGE] year-old male with an initial admitted [DATE]. Relevant diagnoses included occipital neuralgia (severe pain in the back of the head and neck) and idiopathic peripheral autonomic neuropathy (chronic nerve pain and/or numbness). Resident #2's quarterly MDS submitted on 4/1/2025 reflected a BIMS score of 13, indicating intact cognition. Active physician orders for the resident included: a. Fluticasone propionate nasal suspension 50mcg/act, 1 spray in both nostrils in the morning for allergies unsupervised self-administration (order dated 12/13/2024) b. Lidocaine HCl external cream 4%, apply to ble topically at bedtime for neuropathy pain unsupervised self-administration (order dated 12/13/2024) c. Systane complete ophthalmic solution, instill 1 drop in both eyes every 4 hours as needed for dry eyes unsupervised self-administration (order dated 12/13/2024) d. Diclofenac sodium external gel 1%, apply to knees, ankles, feet topically every 6 hours for pain- mild; pain [sic] unsupervised self-administration apply 4 grams (order dated 12/7/2024) Resident #3's facesheet dated 4/17/2025 reflected a [AGE] year-old-male with readmitted [DATE]. Relevant diagnoses included repeated falls, other abnormalities of gait and mobility, and unspecified asthma (a breathing disorder that causes constriction of the airway and inhibits breathing). Resident #3's annual MDS submitted 1/30/2025 reflected a BIMS score of 15, indicating intact cognition. Active physician orders for the resident included: a. Trelegy ellipta inhalation aerosol powder breath activated 200-62.5mcg/act, 1 puff inhale orally one time a day for asthma unsupervised self-administration. Rinse mouth after use (order dated 4/16/2025) Resident #4's facesheet dated 4/17/2025 reflected an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included unspecified asthma and unspecified glaucoma (damage to the nerves of the eye causing vision loss). The annual MDS submitted on 3/25/2025 reported a BIMS score of 15, indicating intact cognition. Active physician orders for the resident included: a. Fluticasone-salmeterol aerosol powder breath active 100-50mcg/dose, 1 inhalation inhale orally every 12 hours for SOB unsupervised self-administration. Rinse mouth after use (order dated 8/31/2024) b. Latanoprost solution 0.005%, instill 1 drop in both eyes at bedtime unsupervised self-administration (order dated 8/28/2024) c. Propylene glycol-glycerin ophthalmic solution 1-0.3%, instill 1 drop in both eyes one time a day for dry eyes unsupervised self-administration (order dated 8/28/2024) d. Timoptic ophthalmic solution 0.5%, instill 1 drop in both eyes two times a day for glaucoma unsupervised self-administration (order dated 8/29/2024) Resident #5's facesheet dated 4/17/2025 reflected a [AGE] year-old female initially admitted to the facility on [DATE]. Relevant diagnoses included other seasonal allergic rhinitis (seasonal allergies causing runny nose), absolute glaucoma, bilateral (vision loss in both eyes from nerve damage), and reduced mobility. Active physician orders for the resident included: a. Artificial tears ophthalmic solution 0.2-0.2-1%, instill 1 drop in both eyes every 4 hours as needed for dry itchy eyes unsupervised self-administration (order dated 8/29/2023) b. Artificial tears ophthalmic solution 0.2-0.2-1%, instill 1 drop in both eyes every 2 times a day for dry itchy eyes unsupervised self-administration (order dated 8/29/2023) c. Biofreeze external gel 4% (menthol topical analgesic), apply to affected areas topically every 6 hours as needed for joint pain unsupervised self-administration (order dated 6/08/2023) d. Biofreeze Professional external gel 5% (menthol topical analgesic), apply to bilateral ankle topically every 4 hours as needed for pain can keep at bedside (order dated 8/30/2024) e. Blink tears ophthalmic gel 0.25%, instill 1 drop in both eyes two times a day for dry eyes unsupervised self-administration (order dated 8/15/2023) f. Voltaren arthritis pain external gel 1%, apply to bil knees and shoulders topically every 6 hours as needed for pain . unsupervised self-administration 4GMs to joints NTE 32 GMs in 24 hours (order dated 6/09/2023) On 4/15/2025 at 1:48 PM, Resident #2 was observed storing 5 medications in a dresser drawer without a lock in his room. Resident #3 was observed on 4/17/2025 at 1:55 PM storing 1 medication in the drawer without a lock of the nightstand next to his bed. Resident #4 was observed storing 4 medications on the top surface of the nightstand on 4/17/2025 at 1:45 PM, and Resident #5 was observed storing 2 medications on top of the bedside table next to the bed on 4/16/2025 at 8:37 AM. All four residents were interviewed at the time of the observations and all reported that the storage method observed was the usual means of storage. In an interview with the DON on 4/17/2025 at 09:13 AM, the DON said medications were safely stored in the rooms of residents who self-administer medications because staff keeps the medications high where they can't reach them. The DON said that residents were told not to keep the medications in their bedside nightstands or anywhere that is in sight. The DON was informed of the survey team's observations of storage of the self-administered meds, and the DON stated she had intentions to implement lockboxes or locking drawers for safety. Record review of a policy related to self-administration of medications reflected the policy does not address storage of medications in a resident's room.

Based on interview and record review, the facility failed to ensure that residents were free from abuse for 1 (Resident #1) of 7 residents reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #1 was free from abuse of unwanted sexual exposure from Resident #6 when he masturbated in front of her. This failure puts residents at risk for abuse and diminished quality of life. Findings included: Record review of Resident #1's facesheet reflected an [AGE] year-old female with admitted [DATE]. Relevant diagnoses included anxiety disorder, depression, and aftercare following joint replacement surgery. Review of Resident #1's quarterly MDS submitted on 4/3/2025 noted that BIMS score was not assessed. The prior quarterly MDS, submitted on 11/21/2024, reflected a BIMS score of 15, indicating intact cognition. Record review of Resident #1's progress notes revealed an entry authored by LVN G on 2/2/2025 at 10:59 PM that stated: Res. Told CNA on Saturday 2-1-25 and Sunday 2-2-25 that her Neighbor has appeared at her door the last two night exposing himself and masturbating at her door [sic]. Further review of Resident #1's progress notes revealed an entry on 2/14/2025 at 5:51 PM, authored by LSW B. In these notes, LSW B documented her interview with Resident #1 about the incident and education to staff regarding the need for staff to notify nurse managers and/or social workers when any incidents related to [resident to resident] occurred. LSW B documented a follow-up progress note on 2/18/2025 at 8:57 AM indicating that the resident's psychologist was notified of the incident and would speak to the resident for evaluation. Record review of the facility's incident report for February 2025 did not reflect an entry for Resident #1, however, in subsequent staff interviews, it was revealed that an investigation had been performed by the facility. Record review of Resident #6's facesheet reflected a [AGE] year-old male with admitted [DATE] and discharge date of [DATE]. Relevant diagnoses included unspecified dementia [a progressive disorder that impairs thought processes, such as memory, thinking, reasoning, and decision-making], unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; cognitive communication deficit; and muscle weakness (generalized). Resident #6's quarterly MDS submitted on 1/30/2025, reflected a BIMS score of 5, indicating severely impaired cognition. In Section E, this MDS also indicated that Resident #6 did not have indicators of psychosis (question E0100), did not have behavioral symptoms exhibited towards others (question E0200), or have history of wandering (E0900). Record review of Resident #6's progress notes revealed an entry on 12/12/2024 noting Resident #6 continu[ed] to roam building. An additional progress note entered on 1/23/2025 noted behaviors: wandering, chronic. On 2/11/2025, an entry by LSW B stated resident found in lobby [with] hands in pants rubbing himself. In an interview with Resident #1 on 4/16/2025 at 8:55 AM, Resident #1 stated she was laying in bed and an unknown man entered her room by wheelchair and began masturbating. She reported that she notified 2 to 3 staff members of the incident, and she was told that the resident had been running around the whole building doing that. She was also told that the man was no longer a resident at the facility. She stated the sexual abuse only happened one time and reported feeling safe at the facility. CNA H was interviewed on 4/29/2025 at 11:34 AM. CNA H stated Resident #1 told her on at least 2 separate occasions that she had been sexually abused by Resident #6. CNA H reported Resident #1 seemed upset and scared when she reported the sexual abuse. CNA H stated she did not witness sexual abuse of Resident #1, nor did she see Resident #6 entering or exiting Resident #1's room. CNA H stated she had observed Resident #6 frequently wandering the resident halls in his wheelchair. CNA H stated that she reported the abuse allegations to LVN G on at least 2 separate occasions. CNA H was unsure of the exact dates that these events occurred but felt certain that 2 of the instances were at least a week apart, as she worked weekend shifts exclusively at the time. CNA H recalled that LVN G's response was dismissive in nature and LVN G attributed Resident #1's allegations to the resident being confused. LVN G also responded that she would speak to the resident. CNA H did not consider Resident #1 to be confused or have altered cognition at the time of the incident. CNA H confirmed during the interview she had participated in training about abuse/neglect and reporting abuse/neglect. At the time of the incident, she was unaware that she should report abuse to the Admin/Abuse Coordinator but received an in-service regarding reporting abuse to the Admin when she made her statement about the incident to the facility. An interview was conducted with LVN G on 4/29/2025 at 12:42 PM. LVN G confirmed she had been the nurse caring Resident #1 on or about 2/2/2025 but denied being told allegations of sexual abuse to Resident #1 by any staff member or the resident. LVN G was unsure if the allegations were factual and felt the allegations were a rumor. She did not witness Resident #6 entering or exiting Resident's #1 room. LVN G did not observe any mood or behavioral changes at the time of the incident. LVN G said she had only heard about the sexual abuse allegations through hearsay or possibly in shift report. LVN G said she did not speak to Resident #1 about the sexual abuse allegations while serving as her primary nurse because she had [her] own problems to deal with. She did not report the abuse to the facility because it was her understanding that the allegations were already known by the facility. She denied knowing which staff member had reported the allegations to the facility. LVN G confirmed she had received training about abuse/neglect and reporting abuse/neglect from the facility. She stated reports of abuse/neglect were to be reported to the Admin. In an interview with LSW B on 4/16/2025 at 9:51 AM, LSW B reported that she was notified on 2/14/2025 of the sexual abuse by a third party professional affiliated with the facility; not by facility staff. After being notified, LSW B stated she immediately met with the resident to assess her for any psychosocial distress and trauma related concerns and had no concerning findings. LSW B stated she reported the incident to the facility abuse coordinator/administrator for further investigation, and she also referred the resident to the psychologist for further evaluation. In a subsequent interview with LSW B on 4/29/2025 at 9:30 AM, LSW B confirmed Resident #6 had been identified during the facility investigation as the alleged perpetrator of the sexual abuse of Resident #1 based on physical description and behaviors. LSW B stated Resident #6 was known to roam the facility, but she was not aware of any instances of him entering any residents' rooms. LSW B confirmed the 2/11/2025 incident documented in Resident #6's progress notes. She stated Resident #6 was observed in the communal lobby area with his hands in his pants and touching his genital area. Another resident observed the behavior and notified her, and LSW B responded by relocating Resident #6 to his room. She then notified the nurse and the Admin of the incident. LSW B reported Resident #6 was not receiving psychiatric services due to the extent of his dementia. In an interview on 4/17/2025 at 9:13 AM, the DON reported the facility's expectation of staff notifying leadership of allegations of abuse/neglect/exploitation is immediate notification. The DON was unsure why LVN G did not notify anyone about Resident #1's abuse allegation. She confirmed that an investigation had been initiated and completed by the facility after becoming aware of the allegations. The DON was unsure if the sexual abuse allegations were reported to the SSA. As a result of the investigation, the DON said she performed staff in-services regarding abuse reporting. The DON was interviewed again on 4/29/2025 at 2:00 PM and reported awareness of Resident #6's wandering behaviors and denied knowledge of sexually inappropriate behaviors other than the incident on 2/11/2025 and the allegations made by Resident #1. She said the wandering behaviors were managed by increased supervision. The DON did not feel like other behavioral interventions were necessary after the 2/11/2025 incident as the resident was pending discharge, on 2/15/25, and the increased supervision was sufficient management. An interview was conducted with the Admin/Abuse Coordinator on 4/17/2025 at 10:23 AM. The Admin confirmed that she was aware of this incident, and stated she had not been notified by facility staff of the incident. She reported a third party performing chart reviews discovered the documentation made by LVN G. The third party notified LSW B, who then notified the Admin and the DON. The Admin reported an investigation of the allegations beginning 2/14/2025 with completion date of 2/18/2025. The Admin reported no additional concerns of abuse from any residents. The Admin said that due to the length of time that elapsed between the incident and the facility becoming aware of it; the pending discharge of the alleged perpetrator; and safe surveys conducted on other residents that did not reveal any concerns of safety from other residents, she did not feel that this warranted reporting to the SSA. The Admin stated if she had been notified immediately by staff of the allegations, she would have reported the incident to the SSA if she felt that the resident was in danger, but she didn't feel like she was. She continued to explain that because the resident did not have any adverse reaction to the sexual abuse and it was a one-time occurrence, she did not feel it was necessary. The admin stated negative outcomes did not determine the threshold of reporting incidents at the facility. The facility provided the internal investigation file related to Resident #1 and the allegations of sexual abuse. Record review of the file revealed: a) transcript of an interview with CNA H dated 2/14/2025 4:19 PM b) 5 Resident Safe Surveys all dated 2/14/2025 c) Record of staff in-service dated 2/18/2025 with DON listed as the instructor. The contents section read any inappropriate behavior between resident to resident must be reported immediately to DON. The in-service included signature pages, signed by 41 staff members. No additional educational materials or handouts were included in the stapled packet. d) Record of staff in-service dated 2/18/2025, titled Abuse and neglect policy with DON listed as the instructor. The signature pages contained 37 staff signatures. A printed copy of the policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program (revised April 2021) was included in the stapled packet. e) Printouts of Resident #1's physician orders, dated 2/18/2025 f) Printouts of Resident #1's progress notes, dated 2/18/2025 In a subsequent interview on 4/29/2025 at 9:15 AM, the Admin stated LVN G's employment was terminated on 2/11/2025 for unrelated performance and behavioral issues. Interview with 10 residents(#2, 16, 17, 18, 19, 20, 21, 22, 23 and 24) on 05/01/2025 between 2:30PM and 3:45PM, for follow up safe survey were asked if any other residents had ever made them feel unsafe or behaved inappropriately towards them, all 10 responded no. A record review of the facility policy titled Accidents and Incidents- Investigating and Reporting revised 2017, indicated in item #1: the nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The policy did not include information regarding submission of the investigation to the SSA. A record review of the facility policy titled Abuse, Neglect, and Exploitation and Misappropriation Prevention Program revised April 2021, reflected in item #9 investigate and report any allegations within timeframes required by federal guidelines.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse are reported not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law established procedures for 1 (Resident #1) of 7 residents reviewed for abuse, neglect, and exploitation. The facility failed to report unwanted sexual exposure/sexual abuse to the Administrator and SSA from a resident to Resident #1. This failure puts residents at risk for abuse and diminished quality of life. Findings included: Record review of Resident #1's facesheet reflected an [AGE] year-old female with admitted [DATE]. Relevant diagnoses included anxiety disorder, depression, and aftercare following joint replacement surgery. Review of Resident #1's quarterly MDS submitted on 4/3/2025 noted that BIMS score was not assessed. The prior quarterly MDS, submitted on 11/21/2024, reflected a BIMS score of 15, indicating intact cognition. Record review of Resident #1's progress notes revealed an entry authored by LVN G on 2/2/2025 at 10:59 PM that stated: Res. Told CNA on Saturday 2-1-25 and Sunday 2-2-25 that her Neighbor has appeared at her door the last two night exposing himself and masturbating at her door [sic]. Further review of Resident #1's progress notes revealed an entry on 2/14/2025 at 5:51 PM, authored by LSW B. In these notes, LSW B documented her interview with Resident #1 about the incident and education to staff regarding the need for staff to notify nurse managers and/or social workers when any incidents related to [resident to resident] occurred. LSW B documented a follow-up progress note on 2/18/2025 at 8:57 AM indicating that the resident's psychologist was notified of the incident and would speak to the resident for evaluation. Record review of the facility's incident report for February 2025 did not reflect an entry for Resident #1, however, in subsequent staff interviews, it was revealed that an investigation had been performed by the facility. Record review of Resident #6's facesheet reflected a [AGE] year-old male with admitted [DATE] and discharge date of [DATE]. Relevant diagnoses included unspecified dementia [a progressive disorder that impairs thought processes, such as memory, thinking, reasoning, and decision-making], unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; cognitive communication deficit; and muscle weakness (generalized). Resident #6's quarterly MDS submitted on 1/30/2025, reflected a BIMS score of 5, indicating severely impaired cognition. In Section E, this MDS also indicated that Resident #6 did not have indicators of psychosis (question E0100), did not have behavioral symptoms exhibited towards others (question E0200), or have history of wandering (E0900). Record review of Resident #6's progress notes revealed an entry on 12/12/2024 noting Resident #6 continu[ed] to roam building. An additional progress note entered on 1/23/2025 noted behaviors: wandering, chronic. On 2/11/2025, an entry by LSW B stated resident found in lobby [with] hands in pants rubbing himself. In an interview with Resident #1 on 4/16/2025 at 8:55 AM, Resident #1 stated she was laying in bed and an unknown man entered her room by wheelchair and began masturbating. She reported that she notified 2 to 3 staff members of the incident, and she was told that the resident had been running around the whole building doing that. She was also told that the man was no longer a resident at the facility. She stated the sexual abuse only happened one time and reported feeling safe at the facility. CNA H was interviewed on 4/29/2025 at 11:34 AM. CNA H stated Resident #1 told her on at least 2 separate occasions that she had been sexually abused by Resident #6. CNA H reported Resident #1 seemed upset and scared when she reported the sexual abuse. CNA stated she did not witness sexual abuse of Resident #1, nor did she see Resident #6 entering or exiting Resident #1's room. CNA H stated she had observed Resident #6 frequently wandering the resident halls in his wheelchair. CNA H stated that she reported the abuse allegations to LVN G on at least 2 separate occasions. CNA H was unsure of the exact dates that these events occurred but felt certain that 2 of the instances were at least a week apart, as she worked weekend shifts exclusively at the time. CNA H recalled that LVN G's response was dismissive in nature and LVN G attributed Resident #1's allegations to the resident being confused. LVN G also responded that she would speak to the resident. CNA H did not consider Resident #1 to be confused or have altered cognition at the time of the incident. CNA H confirmed during the interview she had participated in training about abuse/neglect and reporting abuse/neglect. At the time of the incident, she was unaware that she should report abuse to the Admin/Abuse Coordinator but received an in-service regarding reporting abuse to the Admin when she made her statement about the incident to the facility. An interview was conducted with LVN G on 4/29/2025 at 12:42 PM. LVN G confirmed she had been the nurse caring Resident #1 on or about 2/2/2025 but denied being told by allegations of sexual abuse to Resident #1 by any staff member or the resident. LVN G was unsure if the allegations were factual and felt the allegations were a rumor. She did not witness Resident #6 entering or exiting Resident's #1 room. LVN G did not observe any mood or behavioral changes at the time of the incident. LVN G said she had only heard about the sexual abuse allegations through hearsay or possibly in shift report. LVN G said she did not speak to Resident #1 about the sexual abuse allegations while serving as her primary nurse because she had [her] own problems to deal with. She did not report the abuse to the facility because it was her understanding that the allegations were already known by the facility. She denied knowing which staff member had reported the allegations to the facility. LVN G confirmed she had received training about abuse/neglect and reporting abuse/neglect from the facility. She stated reports of abuse/neglect were to be reported to the Admin. In an interview with LSW B on 4/16/2025 at 9:51 AM, LSW B reported that she was notified on 2/14/2025 of the sexual abuse by a third party professional affiliated with the facility; not by facility staff. After being notified, LSW B stated she immediately met with the resident to assess her for any psychosocial distress and trauma related concerns and had no concerning findings. LSW B stated she reported the incident to the facility abuse coordinator/administrator for further investigation, and she also referred the resident to the psychologist for further evaluation. In a subsequent interview with LSW B on 4/29/2025 at 9:30 AM, LSW B confirmed Resident #6 had been identified during the facility investigation as the alleged perpetrator of the sexual abuse of Resident #1 based on physical description and behaviors. LSW B stated Resident #6 was known to roam the facility, but she was not aware of any instances of him entering any residents' rooms. LSW B confirmed the 2/11/2025 incident documented in Resident #6's progress notes. She stated Resident #6 was observed in the communal lobby area with his hands in his pants and touching his genital area. Another resident observed the behavior and notified her, and LSW B responded by relocating Resident #6 to his room. She then notified the nurse and the Admin of the incident. LSW B reported Resident #6 was not receiving psychiatric services due to the extent of his dementia. In an interview on 4/17/2025 at 9:13 AM, the DON reported the facility's expectation of staff notifying leadership of allegations of abuse/neglect/exploitation is immediate notification. The DON was unsure why LVN G did not notify anyone about Resident #1's abuse allegation. She confirmed that an investigation had been initiated and completed by the facility after becoming aware of the allegations. The DON was unsure if the sexual abuse allegations were reported to the SSA. As a result of the investigation, the DON said she performed staff in-services regarding abuse reporting. The DON was interviewed again on 4/29/2025 at 2:00 PM and reported awareness of Resident #6's wandering behaviors and denied knowledge of sexually inappropriate behaviors other than the incident on 2/11/2025 and the allegations made by Resident #1. She said the wandering behaviors were managed by increased supervision. The DON did not feel like other behavioral interventions were necessary after the 2/11/2025 incident as the resident was pending discharge and the increased supervision was sufficient management. An interview was conducted with the Admin/Abuse Coordinator on 4/17/2025 at 10:23 AM. The Admin confirmed that she was aware of this incident, and stated she had not been notified by facility staff of the incident. She reported an investigation of the allegations beginning 2/14/2025 with completion date of 2/18/2025. The Admin reported no additional concerns of abuse from any residents. The Admin said that due to the length of time that elapsed between the incident and the facility becoming aware of it; the pending discharge of the alleged perpetrator; and safe surveys conducted on other residents that did not reveal any concerns of safety from other residents, she did not feel that this warranted reporting to the SSA. The Admin stated if she had been notified immediately by staff of the allegations, she would have reported the incident to the SSA if she felt that the resident was in danger, but she didn't feel like she was. She continued to explain that because the resident did not have any adverse reaction to the sexual abuse and it was a one-time occurrence, she did not feel it was necessary. The admin stated negative outcomes did not determine the threshold of reporting incidents at the facility. The facility provided the internal investigation file related to Resident #1 and the allegations of sexual abuse. Record review of the file revealed: a) transcript of an interview with CNA H dated 2/14/2025 4:19 PM b) 5 Resident Safe Surveys all dated 2/14/2025 c) Record of staff in-service dated 2/18/2025 with DON listed as the instructor. The contents section read any inappropriate behavior between resident to resident must be reported immediately to DON. The in-service included signature pages, signed by 41 staff members. No additional educational materials or handouts were included in the stapled packet. d) Record of staff in-service dated 2/18/2025, titled Abuse and neglect policy with DON listed as the instructor. The signature pages contained 37 staff signatures. A printed copy of the policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program (revised April 2021) was included in the stapled packet. e) Printouts of Resident #1's physician orders, dated 2/18/2025 f) Printouts of Resident #1's progress notes, dated 2/18/2025 In a subsequent interview on 4/29/2025 at 9:15 AM, the Admin stated LVN G's employment was terminated on 2/11/2025 for unrelated performance and behavioral issues. A record review of the facility policy titled Accidents and Incidents- Investigating and Reporting revised 2017, indicated in item #1: the nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The policy did not include information regarding submission of the investigation to the SSA. A record review of the facility policy titled Abuse, Neglect, and Exploitation and Misappropriation Prevention Program revised April 2021, reflected in item #9 investigate and report any allegations within timeframes required by federal guidelines.

Based on observation, interview and record review the facility failed to follow physician orders and the resident's advance directives for 1 of 24 Residents (Resident #76) whose records were reviewed for DNR code status. The facility failed to ensure nursing staff followed emergency protocol and failed to ensure staff did not provide Resident #76, who had a DNR in place, CPR, after the resident choked and became unresponsive, according to professional standards of practice. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated. These deficient practices could contribute to a resident's decline in emotional, physical and psychological health and result in serious injury and or death. Review of Resident #76's admission record, dated [DATE], revealed she was admitted to the facility on [DATE] with diagnoses to include Dementia (is a progressive brain condition that can cause issues with thinking, behavior, and memory) in other Diseases Classified Elsewhere, Moderate with Agitation, Parkinson's Disease (A chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement) and Dysphagia, Oropharyngeal Phase (A small pouch that forms and collects food particles in your throat, often just above your esophagus, leads to difficulty swallowing, gurgling sounds, bad breath, and repeated throat clearing or coughing). Review of Resident #76's admission MDS assessment, dated [DATE], revealed her BIMS was 01 of 15 reflecting severe cognitive impairment and she required extensive assistance by 1 or 2 persons for ADL's including eating. Review of Resident #76's Care Plan, revised on [DATE], revealed she had a diet alteration related to Resident and family wishes. Resident and family wish for Regular diet, regular texture. The interventions included: Educate patient on nutrient restriction in relation to medical condition/Dx, Diet as ordered, Monitor lab data as available, Monitor meal consumption daily, Notify physician and family/responsible party of weight change, Obtain and update food/beverage preferences. Resident also had an advance Directive as evidenced by DNR. Interventions included: Follow facility protocol for identification of code status. Follow Living Will. Obtain Advance Directive with physician order and resident/responsible party signature. Review of Resident #76's of physician orders for [DATE] revealed she had an order for regular diet, thin regular consistency, dated [DATE]; and an order for DNR, dated [DATE]. Review of Resident #76's Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) revealed it was signed on [DATE]. Review of a cheat sheet with resident's code status observed in rooms 1 to 13 revealed Resident #76's code status was not included. Review of progress note, dated [DATE], at 18:51 (6:51) PM, read as follows: Event Type: Pt choked on chicken and rice at lunch time and then went into cardiac arrest requiring CPR to be performed. Date of Event: [DATE] Time of event: 1215 Detailed description of event (how, when, where, vitals, symptoms): Pt assessed choking on food at lunch time in dining room. Pt not moving air at all and not coughing just showing signs of a blocked airway. Had CNA and LVN try to pull patient out of chair to attempt to do Heimlich maneuver and ,d+[DATE] thrusts given but pt could not stay upright so we lowered pt to ground. 911 called. LVN gave ,d+[DATE] Heimlich maneuver thrusts which did move food a little bit but pt was still choking. At this time pt became unresponsive, carotid pulse palpated with no pulse detected and pt with no respirations. Then CPR was initiated. ,d+[DATE] compressions given per [name], LVN, which caused a big inspiratory gasp and pt opened her eyes then. Pt having shallow respiration but is moving air. Placed pt on right side in the rescue position and continued to attempt to remove what was in her airway. Some chicken and rice were removed. EMS arrives and takes over code. Pt leaves building on stretcher at 1245 with EMS. Patients' description of event: Pt unable to describe event due to dementia. Full Range of Motion Assessment findings (i.e. wnl for resident, or describe abnormal findings): wnl for resident. MD Notification (Date, Time, Method of communication): [DATE] at 1300 (1:00 PM) Responsible Party Notification (Date, Time): [LVN B] notified at 1300 (1:00 PM) Interventions (should address any abnormal assessment findings): Pt transferred to [hospital] ER per EMS. If Fall note-injury, how patient was found, environment, footwear, last toileted, FSBS if diabetic: NA. Review of progress note, dated [DATE] at 18:16 PM (6:16 PM), revealed Resident #76 was admitted to the ICU at a local hospital. Observation at [DATE] in the dining room, on hall B at 12:22 PM, revealed multiple staff (RN A, LVN B and CNA C) with Resident #76. LVN B and CNA C were holding Resident #76 up and she was slumped forward. It looked like the Resident was going to throw up. RN A conducted multiple abdominal thrusts and then told the other staff, We are going to have to lay her down. LVN B and CNA C laid Resident #76 on the floor on her right side. LVN B opened Resident #76's mouth and stated something was stuck in the back of the Resident's throat. She turned Resident #76 on her back and completed multiple rapid abdominal thrusts. She removed some food particles, but LVN B stated the airway was still obstructed. RN A noted Resident #76 was non-responsive, was not able to find her carotid pulse, then instructed LVN B to start CPR. LVN B started performing chest compressions on Resident #76. Resident #76 took a deep breath after about 3 to 5 minutes. RN A then instructed CNA E to call 911 which he proceeded to do from the nurse's station at 12:30 PM. Further observation revealed EMS arrived about 10 to 15 minutes later. Interview on [DATE] at 12:32 PM with a family member revealed she saw Resident #76 choking and told CNA E about it. She stated CNA E walked up to the Resident, asked if she was choking, walked away into room [ROOM NUMBER]. The family member stated it did not have to get this far and the situation could have been prevented had CNA E told someone. Interview on [DATE] at 12:33 PM with CNA E revealed he denied a family member spoke with him. He stated he saw Resident #76 was red and had her hands on her chest. She put her hands down and he asked if she was ok, and she said Yes. CNA E stated he walked into room [ROOM NUMBER] and told CNA C something was going on with Resident #76. CNA C went to check on Resident #76. Interview on [DATE] at 12:41 PM with CNA C revealed she was walking towards the dining room and saw Resident #76 put her hands on her chest. She looked closer and saw Resident #76 was not breathing and looked like she was choking. She told RN A who was standing by the food cart that Resident #76 was not breathing. Interview on [DATE] at 2:15 PM with CNA E stated he was agency staff and had worked at the facility for 10 months. He stated he had been a CNA since 1996. CNA E was asked what was the first thing he should do in an emergency situation. CNA E stated he had been in this situation before and knew what to do. CNA E stated he told CNA C something was going on with Resident #76 because she was the first staff he saw. He stated CNA C looked at Resident #76 and commented Resident #76 was choking and not breathing. CNA E was asked if he reported the incident to a nurse? He changed the subject and said the nurses were passing out trays. He stated they were supposed to stay in the dining room but were not there. CNA E stated CNA C let the nurses know what was going on. He stated he called 911 after RN A told him, but he did not know how to reach the DON because he did not know how to use the phone at the nurse's desk. He stated he started walking down the hall towards the main offices and flagged the DON down when he saw her. Interview on [DATE] at 02:25 PM with RN A revealed her and LVN B were normally in the dining room to supervise the residents during mealtime. RN A stated Resident #76 was eating during lunch time. She stated she had her back to the Resident and was cutting another resident's meat. RN A stated CNA C commented Resident #76 was choking and not breathing. She turned around and saw Resident #76 was turning colors. She stated she responded and tried to perform abdominal thrusts while CNA C and LVN B were holding Resident #76. Resident #76 was slumped over, and flopped down. RN A stated she could not get the technique right because the Resident was slumped over so she told the other staff to lie her down. At that point LVN B tried to conduct abdominal thrusts while the Resident was in supine position. LVN B also tried to dislodge the food by doing a finger sweep. She stated LVN B got some rice and a small piece of chicken out but could not clear Resident #76's throat. RN A stated she looked over at Resident #76 and noted she was blue. She checked for the Resident's carotid pulse but could not find one. RN A stated Resident #76 had agonal breathing (labored, gasping breaths that occur because of insufficient oxygen), and she instructed CNA E to call 911. She stated she checked Resident #76 before she left and had a good bounding (heart is beating faster than normal) caranda pulse but staff and the EMT's could not get a reading on the Resident's O2 saturations. Interview on [DATE] at 3:05 PM with RN A revealed she should have called 911 right away or had another staff to call 911 upon responding to Resident #76's choking. She stated she did not know Resident #76's code status and did not check before or after responding to Resident #76 choking incident. She stated she found out Resident #76 was a DNR when gathering paperwork for the EMT's. She stated they should not have performed CPR with a DNR in place. However, she stated she believed they did what they had to do in responding to the emergency situation. She stated they moved from performing the Heimlich Maneuver to providing CPR because Resident #76 had no pulse. RN A identified at the point she could not find a pulse might have been the deciding factor not to pursue CPR. She stated she was not sure about it. RN A stated she would have to talk with the DON and maybe the physician for clarification. RN A stated staff had to look in PCC to get Resident #76's code status and was not sure if the resident's charts were color coded to alert staff about their code status. She stated she tried calling the DON while LVN B was performing abdominal thrusts, but the DON did not answer her phone. RN A stated once LVN B resuscitated Resident #76, she used the phone at the nurse's desk and paged the DON STAT to hall B. Interview on [DATE] at 3:47 PM with the DON revealed she stated RN A and LVN B did not perform CPR after responding to Resident #76 choking. She stated they only performed the Heimlich Maneuver. Surveyor clarified, per observation, nursing staff performed CPR when RN A and LVN B were not able to clear Resident #76's airway. The DON stated if the Resident was choking, My position is for them to perform CPR, because that's a horrible death. The DON was asked if staff knew Resident #76 had a DNR should they have performed CPR. The DON stated, that would be something we have to look into because I don't agree that anyone should have to die like that. The DON stated in an emergency situation staff should assess the resident and call 911 after establishing it was an emergency. The DON stated staff carried a sheet of paper with the resident's code status and other care needs so they should know when to call 911. The DON stated the resident's DNR status was also on a report sheet at the nurse's station and in PCC. Interview on [DATE] at 4:51 PM with the DON revealed she interpreted the policy as I still would have done it. (DON read policy that stated, Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect.) The DON was informed the Heimlich was unsuccessful and RN A was unable to find a carotid pulse. The DON stated I'm aware that she coded and had no pulse. I see it, she was still choking. I see the chicken in her throat as affecting her having no pulse. I consider someone dead when they have no apical pulse. The DON further stated staff was to check for a DNR right away in the resident's electronic medical record that is my expectation. Interview on [DATE] at 04:52 PM with LVN B revealed she did not know Resident #76's code status when she started CPR. She stated she should not perform CPR when a DNR was in place, and she should have checked Resident 76's code status prior to performing CPR. LVN B stated she did not check. She stated she was not sure about whether or not she should have performed CPR because initially she responded to Resident #76 choking. She performed CPR when she was not able to dislodge the food from the Resident's throat and after RN A could not find a pulse. LVN B stated she thought about the fact she did not know Resident #76's code status when performing CPR. She sated everything happened so fast and she was focused on helping Resident #76. LVN B became tearful during the conversation. LVN B stated would have to look in PCC for the resident's code status. LVN B was not aware of anywhere else she could find a resident's code status during an emergency situation. Interview on [DATE] at 5:15 PM with CNA C revealed she was walking towards the dining room and noticed Resident #76's color was off. She stated CNA E approached her and said he did not know if Resident #76 was having a problem breathing. She stated she walked up to Resident #76, looked at her closer and it looked like she was choking and could not breath. She stated RN A was standing by the food cart and responded right away. CNA C stated LVN B walked around the corner. Then she and LVN B were holding Resident #76 up from her arms because she was not bearing weight. She stated RN A performed some abdominal thrusts, but the Resident was slumped over, so RN A asked them to lie the Resident down. CNA C stated LVN B then tried to do the abdominal thrust again and could not get the food out. LVN B then started CPR when RN A could not find Resident #76's pulse. CNA C stated she did not know Resident #76 code status and could find it in the red book at the nurses station. She stated it was their emergency book. CNA C walked to the nurses station and could not find the red book. She one of the nurse's on assignment and the nurse told CNA C she did not know anything about a red book. Interview on [DATE] at 12:40 PM with Resident #76's family member revealed she talked with facility staff about Resident #76's choking incident which ended up with staff performing CPR. The family member stated she was ok with staff providing CPR because she did not want Resident #76 to choke. The family member did not understand Resident #76 lost consciousness and nursing staff could not find her pulse and then staff performed CPR. The family member did not know facility policy read that nursing staff could not perform CPR once a resident lost consciousness and or could not find a pulse. In addition, the facility CPR policy provided options when addressing other emergency situations for residents who had a DNR in place. The family member stated nursing staff had not discussed any options with her. She stated Resident #76 was placed on what looked like a puree diet when she was initially admitted to the facility and remained on it for a couple of days. Then she asked the facility to put Resident #76 back on a regular diet because she was refusing to eat the puree food. The family member stated facility staff had not talked with her about the results of a completed ST evaluation. She stated it would have helped her in determining the best diet plan for Resident #76 and wondered if Resident #76 would benefit from eating chopped foods. She stated another family member questioned why staff performed CPR because Resident #76 had a DNR in place. The family member stated she was not sure how she would feel if the Resident was in a coma as a result of having CPR. She stated she would be talking to the other family member about Resident #76's DNR code status and would call the facility. Interview on [DATE] at 03:10 PM with Dr. T (MD who signed the DNR), stated Resident #76 had been with their care team since ,d+[DATE] and the last note was entered by an NP, one of the team members. He stated Resident #76 had lost 10% of her body weight and was at end stage Parkinson's, and end stage Dementia. Dr. T stated the team was planning on placing her on hospice soon. He stated the incident with Resident #76 choking and then staff performing CPR was an odd situation and staff could potentially get a resident back if the food was dislodged. He stated he would not start CPR with someone with end stage disease. Dr. T commented, Me personally I wouldn't have started CPR. I can see why the facility started it because she was choking, but she did not have a good quality of life. He stated he would have stated CPR on a patient who was robust. Dr. T wondered how well staff knew Resident #76 and stated it was a tough question; whether or not to perform CPR after a choking incident. He stated almost universally all the patients and families who they talked with and had a DNR did not want CPR even if the patient was choking. Interview on [DATE] at 10:00 AM with the ADM and Regional RN revealed they audited all nursing staff's CPR status and discovered that many of the staff did not have a CPR certification including RN A, LVN B and CNA C. Review of CPR certification status for RN A, LVN B and CNA C revealed they did not have a CPR certification at the time LVN B performed CPR on Resident #76. Review of facility policy, Do Not Resuscitate Order, revised [DATE]), read in part; Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a (Do Not Resuscitate Order in effect. 1. Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident medical record. 3. In addition to the advance directive and DNR order form, state-specific forms may be used to specify whether to administer CPR in case of a medical emergency. State-specific forms include: c. Medical Orders for Life-Sustaining Treatment. e. Clinical Orders for Life Sustaining Treatment. 5. Do Not Resuscitate (DNR) orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order. Review of a facility policy, Emergency Procedure-Cardiopulmonary Resuscitation, revised February 2018, read in part: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual. 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 12:34 PM and the Administrator was notified at 12:34 PM. The Administrator was provided with the IJ template on [DATE]. The following Plan of Removal was accepted on [DATE] at 6:48 p.m. POR LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Preparation and submission of this Plan of removal does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of removal is prepared and submitted solely because of requirements under state and federal laws Verification Plan of Removal: 1. Director of Nursing/designee completed immediate education with RN A, LVN B and CNA C, who were in attendance to emergency on proper response to emergency situation, when to initiate CPR on a resident and include the following steps for emergency response. 1. Staff was trained on [DATE] at 2:15 p.m.; copy of in-service report and sign in sheet provided. 2. Administrator/designee verified status of Resident #76 and was determined by the hospital to be stable and returning to facility on [DATE]. 2. The resident's status at the hospital was verified and a fax from the hospital was provided to the survey team. The fax indicated that the resident was alert and awake and in no acute distress, and was initially on a face mask but was being titrated down. returned to the facility on [DATE]. Her diet order had changed to mechanical soft texture. She was observed by the survey staff on [DATE] between 2:00 p.m. to 3:00 p.m. and also on [DATE] at 3:00 p.m. sitting in her wheelchair by the nursing station. She looked well, her eyes were clear and her pallor was good. Per interview on [DATE] at 3:00 p.m. with the charge nurse, when asked if she had choked on some chicken, her response was, Oh, no, that was my daughter. 3. Director of Nursing/designee validated all resident current Code status was up to date and in EHR, including care planned and on direct care Kardex on [DATE]. 3. Verified; however, the survey team discovered that a total of four (4) OOH-DNR forms were invalid. This was brought to the attention of the Administrator and Regional nurse. They acknowledged the deficiency, and this deficient practice will be cited. 4. The Corporate Clinical Resource completed education with the Director of Nursing regarding requirements on Emergency Response, including following policy titled: Emergency Procedure-Cardiopulmonary Resuscitation on [DATE]. 4. Verified via interview on [DATE] and signed in-service roster. 5. The Corporate nurse completed education with nurse management on requirements to follow resident wishes regarding Code status and CPR, regardless of situation or personal feelings. 5. Verified via interviews on [DATE] and signed in-service roster. 6. Administrator/designee completed sweep of all licensed staff to verify CPR certification status is up to date on [DATE]. Class scheduled to update all certification needed on [DATE] at facility with certified instructor. 6. Verified via list of all licensed staff and their status, and email from instructor indicating she will be at facility at 9:30 a.m. on [DATE]. Also received copy of invoice and proof of payment of $1037.50 for 15 students (two 4-hour sessions) and mileage 7. Identification of all others affected: The DON/designee validated that all residents had up to date code status in EHR, their code is reflected in both care plan and direct care staff Kardex care record on [DATE]. 7. Verified by visually inspecting hard charts, which all had a divider indicating FULL CODE in neon green/yellow or DNR in red, and also checking EHR's. 8. The DON will complete education with all staff on proper procedures to follow in case of Emergency, including initiation of Emergency response system, validating resident code status in EHR, appropriate initiation of CPR, and designating staff in emergent situations to these tasks. Education will specify that any staff responsibility in performing CPR will be delegated to certified personnel, with additional staff to aide in support areas, such as initiating 911, validating code status, etc. Education will be initiated on [DATE] to ensure that staff have a clear understanding of how they should respond during an emergency once they have established a resident's code status prior to performing life sustaining measures to avoid violating the resident's wishes. This education will be ongoing with all staff prior to working their next scheduled shift. 9. DON/designee will complete education regarding initiation of CPR/Emergency response based on resident's code status and wishes, emphasis will be placed on staff understanding of following resident code status indicated in EHR. This education will be ongoing with all staff prior to working their next scheduled shift. ,d+[DATE]. Verified through record review of sign in sheets of training and also in-person interviews of the following staff members: 1. LVN V 2. HR W 3. CNA X 4. CNA Y 5. CNA Z 6. LVN AA 7. LVN BB 8. CNA CC 9. LVN, ADON DD 10. CNA EE 11. CNA FF 12. LVN GG 13. CNA student HH 14. Dietary Manager 15. LVN R 16. RN II 17. Director of Rehabilitation 18. Maintenance Assistant JJ 19. CNA KK 20. LVN LL 10. Ad hoc QAPI meeting held with IDT team and MD to review policy on Emergency Procedure -Cardiopulmonary resuscitation and Plan of removal/response to Immediate Jeopardy Citation on [DATE] at 3:00 p.m. 10. Verified by record review, signed by administrator, medical director (via telephone), DON, both ADON's, and Director of Clinical Operations. A root cause analysis was conducted by the PIP to determine WHY the event occurred. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ after verifying their POR had been initiated and or completed. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 10:00 AM. While the IJ was removed the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated, due to the facility was still monitoring the effectiveness of their Plan of Removal.