Every finding on record at Kennedy Health & Rehab

Based on interview and record review, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week for 1 of 3 months (January 2026) reviewed for the second quarter of the fiscal year 2026.The facility did not have 8 hours of RN coverage for 5 days in January 2026.This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as emergency care and disasters. Findings included:Record review of the RN punch detail hour report for January 2026 indicated the facility did not have 8 hours of RN coverage for the following dates: January 1, 2026; January 6, 2026; January 15, 2026; January 16, 2026; and January 21, 2026.Record review of the CMS Payroll Based Journal (PBJ) report for the second quarter of 2026 (January 1, 2026, to March 31, 2026) indicated the facility did not submit the PBJ staffing data and no RN hours were submitted.During an interview on 8/26/2026 at 2:53 p.m., the DON said she had been employed at the facility since March 2026 but had only been in the DON role for a few months. She said an RN should be in the facility 8 hours each day and was needed to manage resident care, staffing levels, and to ensure everything flowed the way it was supposed to. She said if there was no RN coverage in the facility then there would not be any direct supervisor support or guidance if needed. She said she was not aware the facility did not have enough RN coverage in January 2026.During an interview on 8/26/2026 at 3:42 p.m., the Administrator said she had been employed at the facility since 8/10/2026. She said an RN should be in the facility for 8 hours each day as it was required by state regulation and there could be a risk regardless of if there was one in the facility or not.Record review of a facility policy titled Staffing, Sufficient and Competent Nursing revised August 2022 indicated, .Our facility provides sufficient number of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. 3. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident .

Based on interview and record review the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information on direct care staff turnover and tenure, and on the hours of care provided by each category of staff per resident per day, including, but not limited to, start date, end date, and hours worked for each individual and the facility must submit direct care staff information in the uniform format specified by CMS for 1 of 1 quarters (Fiscal Year 2026 for the second quarter January 1, 2026 to March 31, 2026) reviewed for administration. The facility failed to submit staffing data for quarter January 1, 2026 to March 31, 2026. This failure could place residents at risk for personal needs not being identified and met. Findings include: Record review PBJ Staffing Data Report, fiscal year 2026, quarter two, from January 1, 2026 to March 31, 2026, revealed the facility did not submit the staffing data. During an interview on 8/24/2026 at 3:15 PM, the BOM/HR said she was not in the role of BOM at the beginning of the year. She said the person(s) who would have been responsible were no longer employed with one being the previous Administrator. She said she knew the information was submitted for staffing in the facility. During an interview on 8/26/2026 at 3:42 PM, the Administrator said she had been employed in the facility since 8/10/2026. She said the PBJ report should be submitted quarterly, and it was done to submit the staffing hours for the facility and if it were not done then it could result in fines being placed against the facility. She said it was done to show the facility had adequate staffing. She said the previous Administrator was responsible for submitting the PBJ information and would have to figure out who would be responsible for it going forward. She said she expected it to be submitted quarterly by regulations. She said the facility did not have a policy for PBJ submissions.

Based on interview and record review, the facility failed to conduct a comprehensive assessment of a resident within 14 days after the facility determines or should have determined that there had been a significant change in the resident's physical or mental condition for 1 of 6 residents (Resident #6) reviewed for comprehensive assessments and timing.The facility failed to ensure a Significant Change in Status MDS for Resident #6 was completed within 14 days after hospice admission on [DATE].This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings include:Record review of a facility face sheet dated 8/26/26 for Resident #6 indicated he was a [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnosis of Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia).Record review of a physician's order summary report dated 8/26/26 for Resident #6 indicated he had an order to admit to hospice services on 4/21/26.Record review of a comprehensive care plan initiated on 4/22/26 for Resident #6 indicated he was receiving hospice services.Record review of an electronic medical record on 8/26/26 for Resident #6 indicated he had not had a significant change MDS assessment within 14 days of admitting to hospice services on 4/21/26. During an interview on 8/26/26 at 2:10 pm the MDS nurse said he had only been employed at the facility since 8/1/26 and had received very little training so far. He said there was a nurse coming in to train him, but she worked another job and was only available to come train him on her days off. He said he was working to get the MDS assessments corrected from the previous MDS nurse because they had not been completed correctly. He said he knew a significant change MDS should always be completed within 14 days when a resident admitted to hospice or when they had a significant decline in condition. He said he would be continuing his training and working on getting the assessments correct and completed timely going forward. During an interview on 8/26/26 at 2:50 pm the DON said the MDS nurse was responsible for MDS assessments and ensuring they were completed timely. She said he was new and still training. She said she knew he was working on trying to get things corrected from the previous MDS nurse. She said when a resident admitted to hospice services, they should always have a significant change MDS done. She said that the residents' care plans were generated from the MDS assessments and if they were not completed accurately and timely, residents may not get the care they need. During an interview on 8/26/26 at 3:45 pm the Administrator said she had only been employed for 2 weeks and had not been made aware of any of the issues in the facility. She said, I have a lot of work to do. She had no other response regarding MDS assessments. Record review of CMS RAI manual dated October 2025 revealed: .An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than thedate of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving their highest practicable well-being at whatever stage of the disease process the resident is experiencing.

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of all residents in 1 of 1 memory care unit.The facility did not provide activities for 16 residents residing in the memory care unit.This failure could place residents who could attend activities at risk of boredom, depression, and a decreased quality of life.Findings include: During an observation on 8/24/26 at 9:40 am revealed there were 2 residents observed in the TV room of the secured unit watching television. There were other residents observed wandering up and down the halls. There was no one in the unit attempting to provide any structured activities.During an observation on 8/24/26 at 9:42 am revealed there were 2 residents observed sitting in chairs at front entrance of secured unit near nurse's station. During an observation on 8/25/26 at 8:10 am revealed there were three residents observed wandering up and down the hallway, two residents sitting in chairs in the hallway, and three residents sitting in the TV room watching television. There were no staff observed attempting to provide activities to any residents. During an observation on 8/26/26 at 1:36 pm revealed there were multiple residents observed ambulating in hallway, and four residents sitting in TV room watching television. There were no staff observed attempting to provide any activities for residents. During an interview on 8/26/26 at 2:50 pm the DON said she expected staff to engage residents in activities. She said the Activity Director started sometime in July, 2026, and she said she saw her about a week ago in the unit providing activities. During an interview on 8/26/2026 at 3:24 pm, the AD said she usually did activities in the mornings in the unit and if she went into the unit sometimes, they did not want to play bingo. She said she had 2 activities in the unit but did not always have time to assist with activities. She said she did not know the reason why activities would be offered. She said she did not have any training and thought the job would just be to play with the residents. She said she had other duties in the facility that took her away from getting the activities completed. She had not completed activity director training and said she was actively working on getting her certification. During an interview on 8/26/26 at 3:45 pm the Administrator said she was new and had only been at the facility 2 weeks. She said she could not comment on anything that happened prior to her start, but she said activities should be held in the unit, she was not aware they had been doing any activities. She said she was not aware if the Activity Director had time to do them or not. She said activities gave the residents something to do and kept them occupied and decreased behaviors. She said going forward, she planned on having a specific schedule and assigned staff for the unit to have activities. She said without activities, behaviors could increase.Record review of a facility policy titled Activity Programs dated June 2018 revealed: .Activity programs are designed to meet the interests of and support the physical, mental, and psychological well-being of each resident.

Based on interview and record review the facility failed to review the work of each Certified Nurse Assistant at least once every 12 months, for 7 of 9 (CNA E, CNA F, CNA G, CNA H, CNA K, CNA L, and CNA N) staff reviewed for competency evaluations. The facility failed to complete a competency evaluation for CNA E, CNA F, CNA G, CNA H, CNA K, CNA L, and CNA N. This deficient practice could place residents at risk of not receiving consistent, appropriate interventions necessary to meet the residents' needs. Findings included: Record review of a personnel file review for CNA E indicated she was hired at the facility on 3/20/2025. There was no evidence of an annual competency evaluation being completed for her. Her last competency evaluation was completed on 5/15/2025. Record review of a personnel file review for CNA F indicated she was hired at the facility on 11/21/2024. There was no evidence of an annual competency evaluation being completed for her. Her last competency evaluation was completed on 5/25/2025. Record review of a personnel file review for CNA G indicated she was hired at the facility on 4/8/2026. There was no evidence of a competency evaluation being completed for her. Record review of a personnel file review for CNA H indicated she was hired at the facility on 10/13/2023. There was no evidence of an annual competency evaluation being completed for her. Her last competency evaluation was completed on 5/20/2025. Record review of a personnel file review for CNA K indicated she was hired at the facility on 5/30/2024. There was no evidence of a competency evaluation being completed for her. Record review of a personnel file review for CNA L indicated she was hired at the facility on 9/19/2025. There was no evidence of a competency evaluation being completed for her. Record review of a personnel file review for CNA N indicated she was hired at the facility on 9/9/2025. There was no evidence of a competency evaluation being completed for her. During an interview on 8/26/2026 at 2:53 p.m., the DON said she had been employed at the facility since March 2026 but had only been in the DON role for a few months. She said the ADON was responsible for the CNA competency evaluations yearly and on hire. She said she explained to the BOM/HR that the hiring packet needed to have the competency forms in the packet. She said the competency evaluations were conducted to ensure everyone could perform their duties. She said going forward she would ensure the evaluations were in the hiring packet and ensure the staff were trained. She said if staff did not have competency evaluations, then they could not work. The ADON was unavailable for an interview on 8/26/2026. Record review of the facility assessment dated [DATE] indicated, .Staff Training and competencies: The nursing staff perform competencies at the time of hire and annually thereafter. Staff receive training at the bimonthly staff meetings. The staff receive training on topics such as dementia care, falls, and abuse and neglect. The certified nurse aides are required to complete 12 hours of training that are set forth in the modules provided on the Health and Human Services Website. Record review of a facility policy titled Staffing, Sufficient and Competent Nursing revised August 2022 indicated, .Our facility provides sufficient number of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment .

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment including a qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis for 1 of 1 facility reviewed for food and nutrition services.The facility failed to ensure the director of food and nutrition services received frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.This failure could place the residents at risk of not receiving sufficient food and nutritional services, which could negatively impact the overall resident nutrition.Findings:During an interview on 8/25/2026 at 10:30 am, the Dietary Supervisor said the facility did not have a dietician to consult regarding the needs of the food service department. She said she met with the DON with any changes in residents' care needs and her training was completed independently, or from the previous dietary supervisor. She said a dietician would be good to help with training and overseeing the residents' nutritional needs.During an interview on 8/25/2026 at 10:35 am, the HR Director said she was the previous dietary supervisor, and the facility had not had a consulting dietician for almost a year. She said she could not remember the last time a dietician was in the building or available for consultation. She said the facility had hired a dietician months back, but they never started. She said that the DON assessed resident needs regarding weights and diets and contacted the MD for orders. She said not having a consulting dietician could result in residents not having proper nutritional care. During an interview on 8/25/2026 at 10:37 am, the DON said that she was responsible for oversight of the residents' needs including nutrition. She said she reviewed weights, wounds, and diets, and consulted the MD for new orders. She said the facility had not had a consulting dietician since her hire, and not having a consulting dietician could result in resident care issues related to nutrition. During an interview on 8/25/2026 at 10:40 am, the Administrator said she was not aware there was no consulting dietician for the facility. She said she would investigate the matter. She said not having a consulting dietician could affect the food service department and health of the residents. Record review of an invoice dated 9/30/2025 revealed the last invoice and visit from the registered dietician was on 9/30/2025.Record review of the facility's assessment, dated 4/07/2026, indicated, .The facility also utilizes several consultants and other allied medical staff to provide for resident needs. The facility has a consultant dietitian that comes monthly or more frequently if required to provide dietary assessments and recommendations to assure that the residents are getting their nutritional needs met to prevent unnecessary weight loss or other nutritional deficits. The pharmacy consultant comes monthly to evaluate the medications of the residents, look for contraindications and to destroy medications that are no longer viable.Record review of the facility's policy titled Dietician, dated November 2022, indicated, A qualified, competent, and skilled dietitian will help oversee the food and nutrition services in the facility. 1.A qualified dietitian or other clinically qualified nutrition professional will help oversee food and nutrition services provided to the residents.9. Our facility's dietitian is responsible for, but not necessarily limited to:a. assessing nutritional needs of residents;b. developing and evaluating regular and therapeutic diets;c. developing and implementing person centered education programs involving food and nutrition services for all facility staff;d. overseeing the budget and purchasing of food and supplies;e. food preparation, service and storage; andf. participating in quality assurance and performance improvement (QAPI) when food and nutrition services are involved. 10.The dietitian may oversee and delegate some of the above responsibilities to the director of food and nutrition services .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety requirements and kitchen sanitation. 1. The facility failed to remove a package of ham that had expired on 8/22/2026, from the kitchen refrigerator.2. The facility failed to properly label a round pink meat product in the kitchen refrigerator on 8/24/2026.3. The facility failed to remove a bag of lettuce that had a use by date of 8/09/2026 from the kitchen refrigerator on 8/24/2026.4. The facility failed to remove a gallon of milk that expired as of 8/20/2026 from the kitchen refrigerator on 8/24/2026.5. The facility failed to properly store the scoops for dry goods in the kitchen on 8/24/2026.6. The facility failed to properly store two opened bottles of barbeque sauce that had a label that read to refrigerate after opening on 8/24/2026. These failures could place residents, who received food and beverages from the kitchen, at risk for health complications, foodborne illnesses, and decreased quality of life.Findings:During an observation on 08/24/2026 at 9:15 am, in the kitchen refrigerator, there was a package of ham that expired on 8/22/2026, an unlabeled package of a round pink meat product, package of shredded lettuce with use by date of 8/09/2026, and a gallon of milk with expiration date of 8/20/2026. The dry storage containers of rice, sugar and cornbread mix had the scoops stored in them, and there were 2 bottles of barbeque sauce that were opened on the shelf in the storage room and the label read to refrigerate after opening. During an interview on 08/24/2026 at 9:30 am, the Dietary Supervisor said that she was the one checking for expired foods and removed food weekly with her new food delivery. She said she was not sure how the lettuce had missed her last checks and did not realize barbeque sauce had to be refrigerated after opening. She said she was not aware the scoops could not be stored in the containers but could see how they could contaminate the food if left in there. She said she had been training her new staff, but it has been a process, and she would re-educate on proper storage and labeling of all foods. She said if residents consumed foods that were expired, it could make them sick.During an interview on 08/24/2025 at 10:00 am, the Administrator said that the dietary supervisor was responsible for maintaining the kitchen and ensuring foods were stored appropriately. She said that expired, unlabeled, and improperly stored foods could lead to residents getting sick. Record review of the facility's policy titled Food Receiving and Storage, dated November 2022, indicated, . Foods shall be received and stored in a manner that complies with safe food handling practices. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 12 staff members (CNA P, CNA L, CNA M, CNA N, CNA P, and LVN A) and 4 of 7 residents (Resident #10, Resident #43, Resident #65 and Resident #66) reviewed for infection control.1.The facility failed to ensure CNA P performed hand hygiene after picking food up off the floor with a gloved hand and before opening food for Resident # 43 with the same gloved hand on 8/24/26.2.The facility failed to ensure CNA L and CNA M wore the appropriate PPE for enhanced barrier precautions; washed/sanitized their hands; and did not touch clean items with dirty items during incontinent care provided to Resident #65 on 8/24/2026.3.The facility failed to ensure CNA N and CNA O wore the appropriate PPE for enhanced barrier precautions while performing incontinent care to Resident #10 on 8/25/2026.4.The facility failed to ensure LVN A wore appropriate PPE for EBP while performing supra-pubic catheter care for Resident #66 on 8/26/26.These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings included: 1.Record review of a facility face sheet dated 8/25/26 for Resident #43 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses of cerebral infarction (stroke). Record review of a comprehensive MDS assessment dated [DATE] for Resident #43 indicated a BIMS assessment should not be conducted due to resident being rarely/never understood. A staff assessment for mental status indicated she had severely impaired cognition. She required supervision/touching assistance with eating. Record review of a comprehensive care plan dated 8/11/26 for Resident #43 indicated she had an ADL self-care performance deficit and required supervision with eating. During an observation and interview on 8/24/26 at 12:04 p.m., staff were observed passing trays in dining area of secure unit. CNA P was observed with a glove on her right hand when Resident #43 dropped some food on the floor. CNA P picked the food up off floor, using her gloved hand, and without sanitizing hands or removing the glove, she stood up and opened bread for Resident #43. CNA P said she had only been told to sanitize or wash hands before starting to pass trays and then to sanitize or wash after they were completed. She said she had not been trained to sanitize or wash hands between individual trays or residents. When asked about picking up the food off the floor and then opening food for resident; she said she could see where that would be an infection control issue. 2.Record review of an admission Record for Resident #65 dated 8/24/2026 indicated she was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of encephalopathy (brain damage that alters normal function), quadriplegia (partial or total paralysis in both arms and legs and the body), and focal traumatic brain injury (damage in a localized area of the brain). Record review of a Quarterly MDS Assessment for Resident #65 dated 8/12/2026 indicated she was rarely/never understood with a BIMS score of 0. She was dependent on staff for all ADLs. She was always incontinent of urine/bowel. She had a feeding tube while a resident during the seven day look back period. Record review of a care plan for Resident #65 revised 6/17/2025 indicated she was under enhanced barrier precautions related to a feeding tube. Interventions included for staff to wear proper PPE when entering the room following enhanced barrier precautions. Staff to follow hand hygiene protocol. Record review of active physician orders for Resident #65 dated 8/24/2026 indicated an order for NPO-tube feed diet dated 5/1/2025. During an observation on 8/24/2026 at 3:02 p.m., CNA L and CNA M were in the room to provide incontinent care to Resident #65. Both staff washed their hands and applied gloves. There was a sign on the door for EBP and neither CNA L nor CNA M donned (put on) a gown. The linens were pulled down to the foot of the bed off Resident #65. CNA L opened the resident's brief and pulled it down between the residents' thighs. CNA L removed her gloves and placed them in the trash and did not sanitize or wash her hands after removal. CNA M assisted with holding and repositioning Resident #65. CNA L removed wipes from the package and wiped down both inner thighs and placed the wipe in the trash. CNA L removed a wipe from the package and wiped across her lower abdomen and placed the wipe in the trash. CNA L removed a wipe from the package and down the middle of her vagina from front to back and placed the wipe in the trash. Resident #65 was rolled onto her right side. CNA L removed her gloves and placed them in the trash and donned gloves without washing/sanitizing her hands. CNA L removed a wipe from the package and wiped the resident buttocks from front to back using multiple wipes and placed the wipes in the trash. CNA L rolled the dirty brief underneath her buttocks and then removed her gloves and placed them in the trash. CNA L ran out of gloves and removed gloves from the pocket of CNA M and applied them to her hands without washing or sanitizing them. CNA L removed a wipe from the package and wiped her buttocks and placed it in the trash. CNA L placed a clean brief under the buttocks touching the dirty brief. CNA M removed her gloves and placed them in the trash and sanitized her hands. CNA M removed gloves from her pocket and placed gloves on her hands. Resident #65 was rolled onto her left side, and CNA M removed a wipe from the package and wiped her buttocks and placed them in the trash using multiple wipes. CNA M removed the dirty brief and placed it in the trash. CNA L placed the clean brief under the resident and secured it. CNA L removed her gloves and placed them in the trash. CNA M removed her gloves and placed them in the trash and washed her hands. CNA L repositioned Resident #65 in bed and washed her hands. During an interview on 8/24/2026 at 3:15 pm, CNA L said she had been employed at the facility for eleven months. She said during the care provided to Resident #65 she should have washed her hands after she changed her gloves but guess she was nervous and forgot. She said she should have worn a gown and gloves while care was provided. She said the residents have signs on their doors for EBP. She said she should have removed the dirty brief before placing the clean one under the resident. She said she should have left the room to get more gloves, and staff should not keep gloves in their pockets. She said her last skills check-off was when she hired at the facility. She said there was a risk of cross contamination and spreading germs to other residents. Record review of a personnel file for CNA L revealed she hired at the facility on no record of her having a competency evaluation for hand hygiene or incontinent care. During an interview on 8/24/2026 at 3:28 pm, CNA M said during the care provided to Resident #65 she should have worn a gown. She said gloves should be stored in a plastic bag. She said she had been employed at the facility for almost 2 years. She said her last skills check off was about a month ago. She said there was a risk of carrying germs to other residents if they did not wear a gown when care was provided. 3.Record review of an admission Record for Resident #10 dated 8/26/2026 indicated he was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of intracranial injury, hypotension, and neuromuscular dysfunction of bladder. Record review of active physician orders for Resident #10 dated 4/30/2026 indicated an order for enteral feed every shift. Record review of a Quarterly MDS Assessment for Resident #10 dated 7/3/2026 indicated he had severe impairment in thinking with a BIMS score of 0. He was dependent on staff for all ADLs. He was always incontinent of urine/bowel. He had a feeding tube while a resident in the facility. Record review of a care plan for Resident #10 revised on 5/31/2026 indicated he was under enhanced barrier precautions related to a feeding tube. Interventions included for staff to wear proper PPE when entering the room following enhanced barrier precautions. During an observation on 8/25/2026 at 9:12 a.m., the door of Resident #10's room had a sign for EBP. CNA N and CNA O were in the room and had just finished performing incontinent care. Neither staff were wearing gowns. CNA N was exiting the room with trash in her hand. During an interview on 8/25/2026 at 9:13 a.m., CNA N said she had just changed Resident #10. She said she did not wear a gown while care was provided. She said there was a sign on the door for EBP, but she did not see any PPE in the hallway outside his door or in his room, so she did not wear a gown. She said there could be a risk of spreading germs to other residents if they did not wear the appropriate PPE when care was provided. Record review of a competency evaluation for CNA N revealed no record of a competency evaluation. During an interview on 8/25/2026 at 9:16 a.m., CNA O said she assisted with performing incontinent care to Resident #10 and did not wear a gown. She said there was not any PPE in his room and no one in the facility ever wore any. She said she did see the sign on the door for EBP and was aware what the signage meant. She said by wearing a gown it was to protect the residents from getting infections from the staff and to protect them. Record review of a competency evaluation for CNA O dated 9/4/2025 indicated she was satisfactory with PPE donning and doffing standard precautions and transmission-based precautions. 4. Record review of a facility face sheet dated 8/24/26 for Resident #66 indicated he was a [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including Intellectual disabilities (when limitations in your mental abilities affect intelligence, learning and everyday life skills). Record review of a Quarterly MDS assessment dated [DATE] for Resident #66 indicated a BIMS assessment could not be conducted due to the resident being rarely/never understood. A staff assessment for mental status indicated he had moderately impaired cognition. He had a feeding tube and an indwelling urinary catheter. Record review of a comprehensive care plan dated 8/11/26 for Resident #66 indicated he was under enhanced barrier precautions due to suprapubic catheter and feeding tube. He had intervention to wear proper PPE when entering room following enhanced barrier precautions. During an observation and interview on 8/26/26 at 9:00 a.m., LVN A was observed to perform suprapubic catheter care on Resident #66. She did not put on a gown for EBP. She said she was just nervous and forgot to put her gown on. She said there really was not a system on the secured unit for EBP because they could not leave the signs up or the PPE out because the residents would dig in them and would rip the signs off the doors. She said it could spread infections if EBP were not followed appropriately. During an interview on 8/26/2026 at 2:53 p.m., the DON said she was the IP for the facility and was responsible for training staff on infection control. She said hand hygiene should be performed before and after care, when staff changed their gloves and they should wash their hands. She said residents on EBP included residents with gastrostomy tubes, urinary catheters and wounds. She said if a resident was on EBP staff should wear a gown and gloves and mask, if necessary, when care was provided. She said residents should have a sign at the doorway for EBP that told staff what PPE was required. She said PPE was on the hallways for the staff. She said staff were trained on infection control practices yearly and as needed and would continue to monitor hand hygiene with the staff. She said staff should remove dirty items before placing clean items to prevent cross contamination. She said residents could be at risk of infections if staff did not follow policy and procedures. During an interview on 8/26/2026 at 3:42 p.m., the Administrator said she had been employed in the facility since 8/10/2026. She said the IP for the facility was the DON who was responsible for training staff on infection control and should be ongoing. She said EBP was put in place for residents with IV's, ostomies, wounds, etc. She said staff should wear gowns and gloves when care was provided. She said staff should perform hand hygiene before and after care and between residents when passing meal trays and use hand sanitizer at minimum. She said there was a risk of cross contamination. She said the facility would in-service staff on infection control. Record review of a facility policy titled Hand Washing dated 5/2017 indicated, .It is the policy of this home that hand hygiene is the primary means to prevent the spread of infection. Employed must wash their hands for at least 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: when coming on duty; after handling soiled or used linens; after removing gloves or aprons . Record review of a facility policy titled Enhanced barrier precautions undated indicated, .Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. EBPs employ targeted gown and gloves during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Examples of high-contact resident care activities requiring the use of gowns and gloves for EBPs include: d. providing hygiene .

Based on observation, interview, and record review, the facility failed to ensure the resident's right to personal privacy for 4 of 12 residents reviewed for resident rights. (Residents # 11, # 29, #40, and # 66)1.The facility failed to ensure the room of Resident #29 had a privacy curtain from 8/24/2026 to 8/26/2026. 2.The facility failed to ensure the room of Resident #40 had a privacy curtain from 8/24/2026 to 8/26/2026. 3.The facility failed to provide a privacy curtain in Resident's #11 and #66 room on 8/25/26 and 8/26/26.This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.Findings included:1.Record review of an admission Record dated 8/26/2026 for Resident #29 indicated he was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of type 2 diabetes, hypertension (high blood pressure), dementia (a decline in memory, language and thinking), and atrial fibrillation (irregular heart beat). Record review of an Annual MDS assessment dated [DATE] for Resident #29 indicated he had moderate impairment in thinking with a score of 11. He was independent with toileting and personal hygiene. Record review of a care plan dated 3/2/2023 for Resident #29 indicated he had an ADL self-care performance deficit. Interventions for personal hygiene and toilet use indicated he required supervision.During an observation and interview on 8/24/2026 at 10:10 am, revealed Resident #29 was in his room awake. He said he had been at the facility for a while. There was no privacy curtain noted in the room. He said he did not have a roommate at that time. He said he did not notice the room did not have a curtain for privacy. He said he could go to the bathroom on his own at times and used his urinal. During an observation and interview on 8/25/2026 at 12:09 pm, the HSK Supervisor said Maintenance was responsible for ensuring the privacy curtains were in the resident rooms. She said she gave a list of resident rooms that were missing privacy curtains to the previous Administrator and she was not sure why they were not put up in the rooms. She said it could be a dignity issue if the rooms did not have privacy curtains. She observed both Resident #29 and #40's rooms and said they both should have a privacy curtain in their rooms. During an observation on 8/26/2026 at 12:28 pm, revealed Resident #29 was in his room and there were no privacy curtain in the room.2. Record review of an admission Record dated 8/26/2026 for Resident #40 indicated he was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of type 2 diabetes, Parkinson's disease (a progressive brain disorder that causes problems with movement and balance), and heart failure (heart does not pump effectively). Record review of a Significant Change MDS assessment dated [DATE] for Resident #40 indicated he had moderate impairment in thinking with a BIMS score of 11. He was dependent on staff for toileting hygiene and was always incontinent of urine/bowel. Record review of a care plan for revised 4/2/2026 Resident #40 indicated he had an ADL self-care performance deficit. He was totally dependent on 1-2 staff for toilet use. During an observation and interview on 8/24/2026 at 9:52 am, revealed Resident #40 was in his room sitting in a wheelchair. He said he had been at the facility for 4 years. There was no privacy curtain noted in the room. Resident #40 said he was on hospice and most times he received a bed bath. During an observation on 8/25/2026 at 12:10 pm, revealed Resident #40 was in his room and there was no privacy curtain noted. During an observation on 8/26/2026 at 12:29 pm, revealed Resident #40 was in his room and there was no privacy curtain noted.3.Record review of a facility face sheet dated 8/25/26 for Resident #11 indicated he was a [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnosis of Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia).Record review of a comprehensive MDS assessment dated [DATE] for Resident #11 indicated a BIMS score of 0, which indicated severe cognitive impairment. He required substantial/maximum assistance for all ADLs. Record review of a comprehensive care plan dated 4/24/26 for Resident #11 indicated he was incontinent of bowel and bladder. He had a goal which reflected: .Resident will remain clean, dry and odor free and dignity will be maintained over next 90 days.Record review of a facility face sheet dated 8/24/26 for Resident #66 indicated he was a [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including Intellectual disabilities (when limitations in your mental abilities affect intelligence, learning and everyday life skills).Record review of a Quarterly MDS assessment dated [DATE] for Resident #66 indicated a BIMS assessment could not be conducted due to the resident being rarely/never understood. A staff assessment for mental status indicated he had moderately impaired cognition. He was dependent with all ADLs.Record review of a comprehensive care plan dated 8/11/26 for Resident #66 indicated he was incontinent of bowel, and he had a goal which reflected: .Resident will remain clean, dry and odor free and dignity will be maintained over next 90 days. During an observation and interview on 8/25/26 between 11:20 am and 12:15 pm LVN A was observed to provide a bolus tube feeding and administer G/tube (a tube inserted into the stomach to provide nutrition and medications) medications to Resident #11 without providing privacy from his roommate (Resident #66) who was sleeping in his bed on his side of the room. After providing care, LVN A was asked about the privacy curtain, and she said there was not a curtain to pull in order to provide privacy between the roommates. She said she did close the door and pull the curtain that was between Resident #11 and the door to the hallway, but there was not a curtain or even a track to install a curtain between the residents to be able to provide privacy. She said the facility was aware of this issue as she thought it was brought to their attention last year. She said she was unsure if either resident was cognitively aware enough to realize they had not been provided with privacy. She said she would not want to have personal care performed on her without privacy being provided. During an observation on 8/26/26 at 9:00 am Resident #11 was observed lying in bed in his room sleeping while LVN A performed suprapubic catheter (a tube inserted directly into the bladder to drain urine) care on Resident #66. There was no privacy curtain available to provide privacy between residents.During an interview on 8/26/2026 at 2:20 pm, the Maintenance Supervisor said he had been at the facility for 3 weeks. He said during his first week he was given a logbook for issues that needed follow through. He said he was not made aware of any rooms in the facility that needed privacy curtains or that needed tracks for the privacy curtains. He said privacy curtains were used for privacy and if someone was exposed, they could cover them up. He said residents need their privacy, he said he would not want to be in bed naked and have other people able to see him, that it would be embarrassing.During an interview on 8/26/2026 at 2:53 pm, the DON said she has been employed at the facility since March 2026 but had only been in the DON role for a few months. She said every resident should have a privacy curtain in their room. She said maintenance and housekeeping were aware and curtains had been ordered. She said if the rooms did not have privacy curtains it was a dignity issue and everyone deserved privacy when care was provided.During an interview on 8/26/2026 at 3:42 pm, the Administrator said she had been in the facility since 8/10/2026. She said she was made aware of some rooms in the facility that needed privacy curtains. She said privacy curtains were needed for privacy when care was provided. She said if there was not a privacy curtain then there could be a dignity issue.Record review of a facility policy titled Dignity revised February 2021 indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with lift, and feeling of self-worth and self-esteem. 11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. A privacy curtain will be maintained and utilized in rooms occupied by more than one resident .

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 1 of 1 secured unit reviewed for environmental concerns, in that:1. The facility failed to ensure the secured unit common areas and hallways did not have soiled floors, chipped paint and holes in the sheetrock, peeling paint on handrail, hole in top left corner of end hall exit door, and peeling vinyl from dining chairs on 8/24/26.2.The facility failed to ensure resident rooms [ROOM NUMBERS] did not have soiled floors on 8/24/26.3.The facility failed to ensure the hallway was not dimly lit on the 800-hallway leading to common areas (TV room and Dining area) of secured unit.4.The facility failed to ensure room [ROOM NUMBER]'s door finish was not peeling off exposing particle board underneath it on 8/24/26.These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.Findings include:During an observation on 8/24/26 at 9:41 a.m., multiple spots of a brown substance were observed in the floor on the 900-hallway (secured unit), and a handrail in the 900-hallway was observed with a large patch of missing/peeling paint. During an observation on 8/24/26 at 9:50 a.m., room [ROOM NUMBER] was observed to be dirty with a black, caked substance observed on the floor near baseboards with white specks of debris mixed in.During an observation on 8/24/26 at 10:00 a.m., room [ROOM NUMBER] door was observed with the finish peeling off, exposing particle board underneath. The floor in room [ROOM NUMBER] was observed with multiple spots of a black substance and what appeared to be peeling laminate from the floor. The bathroom was observed with an orange substance in the floor underneath the sink, next to the toilet underneath a plunger, and multiple brown spots in the floor.During an observation on 8/24/26 at 12:00 p.m., the exit door at the end of the 900 hallway was observed with broken tiles at the bottom of door and caked up dirt and grime along bottom of door jamb. There was a hole observed in the top left corner of the exit door, approximately 2cm X 2cm, with exposure to the outside elements. During an observation on 8/24/26 at 12:04 p.m., the dining area in the secured unit at the end of the 800-hallway was observed to have missing paint on the walls, dining chairs with large patches of missing vinyl exposing the cushion beneath. The exit door in the dining area was observed with broken tiles at the bottom of the doorway and caked up dirt and grime at the door jamb. The common area (TV room) at the end of the 800-hallway next to dining area was observed with multiple areas of missing paint with exposed sheetrock. The 800-hallway leading to the common areas was dimly lit.During an interview on 8/24/26 at 10:00 a.m., Resident #24 said that the dirty floor bothers him, he said he does not like it and that roaches sometimes crawl all over the floors and walls.During an interview on 8/26/26 at 2:00 p.m., the Housekeeping Supervisor said housekeeping staff were responsible for cleaning the facility. She said staff go to the unit at least a couple of times a day. She said they were having trouble getting the chemicals and equipment they need from corporate to be able to properly clean. She said she was buying supplies with her own money, she said the facility does reimburse her, but she said she just went yesterday to buy paper towels and toilet paper for the facility because her laundry/housekeeping budget would not allow her to order them. She said she knew the floors in the unit needed to be stripped and deep cleaned, but corporate would not get the supplies needed to do the task. She said they would need a stripper in order to properly strip and rewax the floors, but they could not get corporate to get them one. She said the facility would not supply any air fresheners to help with the odors, only bleach and sometimes [brand of multi-surface cleaner]. She said if the facility was not kept properly clean, it could attract pests, residents could get sick, or it could possibly cause a fall.During an interview on 8/26/26 at 2:20 p.m., the Maintenance Director said he had only been here 3 weeks. He said he had not received any training on what his job responsibilities were. He said he felt like when he started, he was just basically told good luck. When asked what he was told about his job when he hired, he replied If it's broke, fix it. He said he knew the unit had multiple environmental issues, he said residents did not deserve to live like that and if issues were not fixed, then pests could enter the building like rats or snakes. He said residents could get sick or be exposed to germs, and pests could possibly get in the food. He said the secured unit smells like piss and shit and the entire facility [NAME]. He said he would not want to live in that environment. He said going forward, he was going to assess the facility and try and fix what he could. During an interview on 8/26/26 at 2:50 p.m., the DON said she would not want to live back there. She said the environmental issues needed to be fixed so residents could have a clean, homelike environment to live in.During an interview on 8/26/26 at 3:45 p.m., the Administrator said she and the DON were both new. She said she had only been here 2 weeks. She said she expected corporate to work on things and they were aware of the issues. She said I have alot to do and had no further comments.Record review of a facility policy titled Homelike Environment dated February 2021 read: .Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 6 residents (Resident #24) reviewed for pest control.The facility failed to ensure an effective pest control program was in place to keep roaches out of the facility on 8/24/2026.These failures could place residents at risk of injury due to an ineffective pest control program at the facility.Findings included:Record review of a facility face sheet dated 8/25/26 for Resident #24 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Alzheimer's disease.Record review of a quarterly MDS assessment dated [DATE] for Resident #24 indicated a BIMS score of 6, indicating he had severely impaired cognition.During an observation on 8/24/26 at 10:19 a.m., a live roach was observed crawling on floor close to nurses' station for secured unit and was then observed crawling down hallway where administrative offices are located.During an observation on 8/25/2026 at 11:33 am and again at 12:00 pm there was a live roach crawling on the wall and venti hood in the kitchen. During an interview on 8/24/26 at 10:00 a,m,. Resident #24 said that the dirty floors in the secured unit bothered him, he said he did not like it and that roaches sometimes crawl all over the floors and walls.During an interview on 8/25/2026 at 12:05 pm the Dietary Supervisor said that roaches had been a problem in the kitchen since she started to work. She said pest control came last month and was not sure how often they should be coming. She said she and her staff kill them as they see them and try to keep all items stored in lidded containers. She said having roaches was not sanitary and could make residents sick.During an interview on 8/26/26 at 2:20 p.m., the Maintenance Director said he had only been employed at the facility for 3 weeks. He said he had not received any training on what his job responsibilities were. He said he felt like when he was hired, he was basically told good luck. He said he had not been made aware that pest control was part of his job responsibility. When asked what he was told about his job when he hired, he replied If it's broke, fix it. He said he knew the unit had multiple environmental issues, he said residents did not deserve to live like that and if issues were not fixed, then pests could enter the building like rats, or snakes. He said residents could get sick or be exposed to germs, and that pests could possibly get into the food. He said the secured unit smells like piss and shit and the entire facility [NAME]. He said he would not want to live in that environment. He said going forward, he was going to assess the facility and try to fix what he could. During an interview on 8/26/26 at 2:50 p.m., the DON said she expected the facility to be as pest free as possible and said that pest control came and sprayed yesterday (8/25/26). She said they also came a couple of weeks ago. She said pests could get into the food and some pests' bite.During an interview on 8/26/26 at 3:45 p.m., the Administrator said she was new and had only been here 2 weeks. She said she expected to attempt to keep the facility free from pests. She simply said I have alot to do She had no further comments.Record review of a facility policy titled Homelike Environment dated February 2021 read: .Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible . Record review of a facility policy titled Pest Control dated May 2008 read: .This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on interview and record review the facility failed to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles and determine the amount and types of training necessary based on a facility assessment for 4 of 14 employees (LVN C, LNV D, CNA E, and CNA G) reviewed for training. The facility failed to ensure training on dementia, fall prevention, HIV, and restraint was provided to LVN C, LVN D, CNA E and CNA G. This failure could place residents at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being . Findings include: Record review of the personnel file for LVN C indicated she was hired at the facility on 11/12/2025. There was no evidence of dementia, fall prevention, HIV, and restraint training in her file. Record review of the personnel file for LVN D indicated she was hired at the facility on 1/5/2026. There was no evidence of dementia, fall prevention, HIV, and restraint training in her file. Record review of the personnel file for CNA E indicated she was hired at the facility on 3/20/2025. There was no evidence of dementia, fall prevention, HIV, and restraint training in her file. Record review of the personnel file for CNA G indicated she was hired at the facility on 4/8/2026. There was no evidence of dementia, fall prevention, HIV, and restraint training in her file. During an interview on 8/26/2026 at 2:53 PM, the DON said she had been employed at the facility since March 2026, but had only been in the DON role for a few months. She said the ADON was responsible for the CNA competency evaluations yearly and on hire. She said the trainings were done to ensure everyone could perform their duties. She said if competencies were not completed then the staff could not work. The ADON was unavailable for an interview on 8/26/2026. During an interview on 8/26/2026 at 3:42 PM, the Administrator had been in the facility since 8/10/2026. She said she did not know what type of training was provided to the staff in the facility. She said training was to be provided for the staff so they would know how to do their jobs correctly along with competency evaluations. She said residents could be at risk of being injured if staff did not complete competency evaluations. Record review of the facility assessment, dated 4/7/2026, indicated, .Staff Training and competencies: The nursing staff perform competencies at the time of hire and annually thereafter. Staff receive training at the bimonthly staff meetings. The staff receive training on topics such as dementia care, falls, and abuse and neglect. Record review of a facility policy titled Staffing, Sufficient and Competent Nursing revised August 2022 indicated, .Our facility provides sufficient number of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Competent Staff 3. Staff must demonstrate the skills and techniques necessary to care for the resident needs including (but not limited to) the following areas: a. Resident rights, d. dementia care.

Based on interview and record review the facility failed to ensure effective communications mandatory training for direct care staff was included for 4 of 14 employees (LVN C, LVN D, CNA E, and CNA G) reviewed for training. The facility failed to ensure effective communication training was provided to LVN C, LVN D, CNA E, and CNA G. This failure could place residents at risk of miscommunication and social isolation. Findings include: Record review of the personnel file for LVN C indicated she was hired at the facility on 11/12/2025 and did not have training on effective communication. Record review of the personnel file for LVN D indicated she was hired at the facility on 1/5/2026 and did not have training on effective communication. Record review of the personnel file for CNA E indicated she was hired at the facility on 11/21/2024 and did not have training on effective communication. Record review of the personnel file for CNA G indicated she was hired at the facility on 4/8/2026 and did not have training on effective communication. During an interview on 8/25/2026 at 9:20 AM, the BOM/HR said staff training was done by in-services and most staff did not have training when personnel files were reviewed. She said the DON was responsible for staff training. During an interview on 8/26/2026 at 2:53 PM, the DON said she has been employed at the facility since March 2026, but had only been in the DON role for a few months. She said the ADON was responsible for the CNA competency evaluations yearly and on hire. She said the trainings were done to ensure everyone could perform their duties. She said if competencies were not completed then the staff could not work. The ADON was unavailable for an interview on 8/26/2026. During an interview on 8/26/2026 at 3:42 PM, the Administrator had been in the facility since 8/10/2026. She said she did not know what type of training was provided to the staff at the facility. She said training was to be provided to the staff so they would know how to do their jobs correctly along with competency evaluations. She said residents could be at risk of being injured if staff did not complete competency evaluations. Record review of the facility assessment, dated 4/7/2026, indicated, .Staff Training and competencies: The nursing staff perform competencies at the time of hire and annually thereafter. Record review of a facility policy titled Staffing, Sufficient and Competent Nursing, revised August 2022, indicated, .Our facility provides sufficient number of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. f. communication

Based on interview and record review the facility failed to ensure staff members were educated on the rights of the resident and the responsibilities of a facility to properly care for its residents for 4 of 14 employees (LVN C, LVN D, CNA E, and CNA G) reviewed for training. The facility failed to ensure LVN C, LVN D, CNA E, and CNA G received training on resident rights. This failure could place residents at risk of miscommunication and social isolation. Findings include: Record review of the personnel file for LVN C indicated she was hired at the facility on 11/12/2025 and did not have training on resident rights. Record review of the personnel file for LVN D indicated she was hired at the facility on 1/5/2026 and did not have training on resident rights. Record review of the personnel file for CNA E indicated she was hired at the facility on 11/21/2024 and did not have training on resident rights. Record review of the personnel file for CNA G indicated she was hired at the facility on 4/8/2026 and did not have training on resident rights. During an interview on 8/25/2026 at 9:20 AM, the BOM/HR said staff training was done by in-services and most staff did not have training when personnel files were reviewed. She said the DON was responsible for staff training. During an interview on 8/26/2026 at 2:53 pm, the DON said she had been employed at the facility since March 2026 but had only been in the DON role for a few months. She said the ADON was responsible for the CNA competency evaluations yearly and on hire. She said the trainings were done to ensure everyone could perform their duties. She said if competencies were not completed then the staff could not work. The ADON was unavailable for an interview on 8/26/2026. During an interview on 8/26/2026 at 3:42 PM, the Administrator had been in the facility since 8/10/2026. She said she did not know what type of training was provided to the staff at the facility. She said training was to be provided to the staff so they would know how to do their jobs correctly along with competency evaluations. She said residents could be at risk of being injured if staff did not complete competency evaluations. Record review of the facility's assessment, dated 4/7/2026, indicated, .Staff Training and competencies: The nursing staff perform competencies at the time of hire and annually thereafter. Staff receive training at the bimonthly staff meetings. Record review of a facility policy titled Staffing, Sufficient and Competent Nursing, revised August 2022, indicated, .Our facility provides sufficient number of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. a. Resident rights

Based on interview and record review the facility failed provide training to their staff that at minimum educated staff on activities that constituted abuse, neglect, exploitation, and misappropriation of resident property for 4 of 14 employees (LVN C, LVN D, CNA E, and CNA G) reviewed for training. The facility failed to ensure LVN C, LVN D, CNA E and CNA G received training on abuse. This failure could place residents at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: Record review of the personnel file for LVN C indicated she was hired at the facility on 11/12/2025 and did not have training on abuse. Record review of the personnel file for LVN D indicated she was hired at the facility on 1/5/2026 and did not have training on abuse. Record review of the personnel file for CNA E indicated she was hired at the facility on 11/21/2024 and did not have training on abuse. Record review of the personnel file for CNA G indicated she was hired at the facility on 4/8/2026 and did not have training on abuse. During an interview on 8/25/2026 at 9:20 AM, the BOM/HR said staff training was done by in-services and most staff did not have training when personnel files were reviewed. She said the DON was responsible for staff training. During an interview on 8/26/2026 at 2:53 PM, the DON said she had been employed at the facility since March 2026, but had only been in the DON role for a few months. She said the ADON was responsible for the CNA competency evaluations yearly and on hire. She said the trainings were done to ensure everyone could perform their duties. She said if competencies were not completed then the staff could not work. The ADON was unavailable for an interview on 8/26/2026. During an interview on 8/26/2026 at 3:42 PM, the Administrator had been in the facility since 8/10/2026. She said she did not know what type of training was provided to the staff at the facility. She said training was to be provided to the staff so they would know how to do their jobs correctly along with competency evaluations. She said residents could be at risk of being injured if staff did not complete competency evaluations. Record review of the facility's assessment, dated 4/7/2026, indicated, .Staff Training and competencies: The nursing staff perform competencies at the time of hire and annually thereafter. Staff receive training at the bimonthly staff meetings.

Based on interview and record review the facility failed to ensure as part of its QAPI program mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI program and informed staff of the elements and goals of the facility's QAPI program for 8 of 14 employees (LVN C, LVN D, DOR, CNA E, CNA F, CNA G, CNA H and CNA K) reviewed for training. The facility failed to ensure quality assurance and performance improvement training was provided to LVN C, LVN D, DOR, CNA E, CNA F, CNA G, CNA H and CNA K. This failure could place residents at risk for not being aware of facility programs, implementation, and monitoring.Findings include: Record review of the personnel file for LVN C indicated she was hired at the facility on 11/12/2025. There was no evidence of training on QAPI. Record review of the personnel file for LVN D indicated she was hired at the facility on 1/5/2026. There was no evidence of training on QAPI. Record review of the personnel file for the DOR indicated she was hired at the facility on 8/1/2015. There was no evidence of training on QAPI. Record review of the personnel file for CNA E indicated she was hired at the facility on 3/20/2025. There was no evidence of training on QAPI. Record review of the personnel file for CNA F indicated she was hired at the facility on 11/21/2024. There was no evidence of training on QAPI. Record review of the personnel file for CNA G indicated she was hired at the facility on 4/8/2026. There was no evidence of training on QAPI. Record review of the personnel file for CNA H indicated she was hired at the facility on 10/13/2023. There was no evidence of training on QAPI. Record review of the personnel file for CNA K indicated she was hired at the facility on 5/30/2024. There was no evidence of training on QAPI. During an interview on 8/25/2026 at 9:20 AM, the BOM/HR said staff training was done by in-services and most staff did not have training when personnel files were reviewed. She said the DON was responsible for staff training. During an interview on 8/26/2026 at 2:53 PM, the DON said she had been employed at the facility since March 2026, but had only been in the DON role for a few months. She said the ADON was responsible for the CNA competency evaluations yearly and on hire. She said the trainings were done to ensure everyone could perform their duties. She said if competencies were not completed then the staff could not work. The ADON was unavailable for an interview on 8/26/2026. During an interview on 8/26/2026 at 3:42 PM, the Administrator had been in the facility since 8/10/2026. She said she did not know what type of training was provided to the staff at the facility. She said training was to be provided to the staff so they would know how to do their jobs correctly along with competency evaluations. She said residents could be at risk of being injured if staff did not complete competency evaluations. Record review of the facility assessment, dated 4/7/2026, indicated .Staff Training and competencies: The nursing staff perform competencies at the time of hire and annually thereafter. Staff receive training at the bimonthly staff meetings. Record review of a facility policy titled Staffing, Sufficient and Competent Nursing, revised August 2022, indicated, .Our facility provides sufficient number of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment.

Based on interview and record review the facility failed to include as part of its infection prevention and control program mandatory training that included the written standards, policies, and procedures for the program for 4 of 14 staff (LVN C, LVN D, CNA E and CNA G) reviewed for training. The facility failed to ensure infection prevention and control training was provided to LVN C, LVN D, CNA E, and CNA G on hire. This failure could place residents at risk to the spread of illness. Findings include: Record review of the personnel file for LVN C indicated she was hired at the facility on 11/12/2025 and did not have training on infection control. Record review of the personnel file for LVN D indicated she was hired at the facility on 1/5/2026 and did not have training on infection control. Record review of the personnel file for CNA E indicated she was hired at the facility on 11/21/2024 and did not have training on infection control. Record review of the personnel file for CNA G indicated she was hired at the facility on 4/8/2026 and did not have training on infection control. During an interview on 8/25/2026 at 9:20 AM, the BOM/HR said staff training was done by in-services and most staff did not have training when personnel files were reviewed. She said the DON was responsible for staff training. During an interview on 8/26/2026 at 2:53 PM, the DON said she had been employed at the facility since March 2026 but had only been in the DON role for a few months. She said the ADON was responsible for the CNA competency evaluations yearly and on hire. She said the trainings were done to ensure everyone could perform their duties. She said if competencies were not completed then the staff could not work. The ADON was unavailable for an interview on 8/26/2026. During an interview on 8/26/2026 at 3:42 PM, the Administrator had been in the facility since 8/10/2026. She said she did not know what type of training was provided to the staff at the facility. She said training was provided to the staff so they would know how to do their jobs correctly along with competency evaluations. She said residents could be at risk of being injured if staff did not complete competency evaluations. Record review of a facility policy titled Staffing, Sufficient and Competent Nursing revised August 2022 indicated, .Our facility provides sufficient number of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. l. infection control

Based on interview and record review the facility failed to ensure the operating organization for each facility included compliance and ethics program annual training if the operating organization operated five or more facilities for 14 of 14 employees (Administrator, DON, ADON, LVN A, LVN C, LVN D, AD, DM, DOR, CNA E, CNA F, CNA G, CNA H and CNA K) reviewed for training in that: The facility failed to ensure annual compliance and ethics training was provided to the Administrator, DON, ADON, LVN A, LVN C, LVN D, AD, DM, DOR, CNA E, CNA F, CNA G, CNA G, CNA H and CNA K. This failure could place them at risk of poor care or victimization.Findings include: Record review of the personnel file for the Administrator indicated she was hired at the facility on 8/10/2026. There was no evidence of training on compliance and ethics. Record review of the personnel file for the DON indicated she was hired at the facility on 3/30/2026. There was no evidence of training on compliance and ethics. Record review of the personnel file for the ADON indicated he was hired at the facility on 6/15/2026. There was no evidence of training on compliance and ethics. Record review of the personnel file for LVN A indicated she was hired at the facility on 6/8/2026. There was no evidence of training on compliance and ethics. Record review of the personnel file for LVN C indicated she was hired at the facility on 11/12/2025. There was no evidence of training on compliance and ethics. Record review of the personnel file for LVN D indicated she was hired at the facility on 1/5/2026. There was no evidence of training on compliance and ethics. Record review of the personnel file for the AD indicated she was hired at the facility on 1/8/2026. There was no evidence of training on compliance and ethics. Record review of the personnel file for the DM indicated she was hired at the facility on 5/21/2026. There was no evidence of training on compliance and ethics. Record review of the personnel file for the DOR indicated she was hired at the facility on 8/1/2015. There was no evidence of training on compliance and ethics. Record review of the personnel file for CNA E indicated she was hired at the facility on 3/20/2025. There was no evidence of training on compliance and ethics. Record review of the personnel file for CNA F indicated she was hired at the facility on 11/21/2024. There was no evidence of training on compliance and ethics. Record review of the personnel file for CNA G indicated she was hired at the facility on 4/8/2026. There was no evidence of training on compliance and ethics. Record review of the personnel file for CNA H indicated she was hired at the facility on 10/13/2023. There was no evidence of training on compliance and ethics. Record review of the personnel file for CNA K indicated he was hired at the facility on 5/30/2024. There was no evidence of training on compliance and ethics. During an interview on 8/25/2026 at 9:20 AM, the BOM/HR said staff training was done by in-services and most staff did not have training when personnel files were reviewed. She said the DON was responsible for staff training. During an interview on 8/26/2026 at 2:53 PM, the DON said she had been employed at the facility since March 2026, but had only been in the DON role for a few months. She said the ADON was responsible for the CNA competency evaluations yearly and on hire. She said the trainings were done to ensure everyone could perform their duties. She said if competencies were not completed then the staff could not work. The ADON was unavailable for an interview on 8/26/2026. During an interview on 8/26/2026 at 3:42 PM, the Administrator had been in the facility since 8/10/2026. She said she did not know what type of training was provided to the staff at the facility. She said training was to be provided to the staff so they would know how to do their jobs correctly along with competency evaluations. She said residents could be at risk of being injured if staff did not complete competency evaluations. Record review of the facility's assessment, dated 4/7/2026, indicated .Staff Training and competencies: The nursing staff perform competencies at the time of hire and annually thereafter. Staff receive training at the bimonthly staff meetings. Record review of a facility policy titled Staffing, Sufficient and Competent Nursing, revised August 2022, indicated .Our facility provides sufficient number of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment

Based on interview and record review the facility failed to provide behavioral health training as determined by the facility assessment for 4 of 14 employees (LVN C, LNV D, CNA E, and CNA G) reviewed for training. The facility failed to ensure behavioral health training was provided to LVN C, LVN D, CNA E and CNA G. This failure could place residents at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being.Findings include: Record review of the personnel file for LVN C indicated she was hired at the facility on 11/12/2025. There was no evidence of behavioral health training in her file. Record review of the personnel file for LVN D indicated she was hired at the facility on 1/5/2026. There was no evidence of behavioral health training in her file. Record review of the personnel file for CNA E indicated she was hired at the facility on 3/20/2025. There was no evidence of behavioral health training in her file. Record review of the Personnel file for CNA G indicated she was hired at the facility on 4/8/2026. There was no evidence of behavioral health training in her file. During an interview on 8/26/2026 at 2:53 PM, the DON said she had been employed at the facility since March 2026 but had only been in the DON role for a few months. She said the ADON was responsible for the CNA competency evaluations yearly and on hire. She said the trainings were done to ensure everyone could perform their duties. She said if competencies were not completed then the staff could not work. The ADON was unavailable for an interview on 8/26/2026. During an interview on 8/26/2026 at 3:42 PM, the Administrator had been in the facility since 8/10/2026. She said she did not know what type of training was provided to the staff in the facility. She said training was to be provided to the staff so they would know how to do their jobs correctly along with competency evaluations. She said residents could be at risk of being injured if staff did not complete competency evaluations. Record review of a facility policy titled Staffing, Sufficient and Competent Nursing revised August 2022 indicated, .Our facility provides sufficient number of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment, b. behavioral health .

Based on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 2 residents (Resident #9 and Resident #58) reviewed for Medicare/Medicaid coverage.The facility failed to ensure Resident #9 and Resident #58 were given a SNF ABN (is document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility prior to covered days being exhausted.This failure could place residents at risk for not being aware of changes to provided services.Findings included:1. Record review of an admission Record for Resident #9 dated 8/26/2026 indicated he was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of cerebral infarction (stroke), major depressive disorder (persistent sadness or loss of interest) and hypertension (high blood pressure). He discharged home on 6/24/2026.Record review of an admission MDS Assessment for Resident #9 dated 4/1/2026 indicated the assessment was for a Medicare Part A stay. He had severe impairment in thinking with a BIMS score of 4. Record review of a care plan for Resident #9 dated 4/20/2026 indicated he was receiving therapy for rehab that included speech therapy. Interventions included to provide therapy per order.Record review of a SNF Beneficiary Protection Notification Review for Resident #9 indicated his Medicare Part A skilled services episode start date 4/24/26. His last covered day of part A service was 6/24/26. There was no evidence of an SNF ABN or NOMNC form was given to the resident or family or the Skilled Nursing facility Advanced Beneficiary Notice (SNF ABN) CMS form 10055 was not completed which would have informed Resident #9 of the option to continue services at a private pay rate.2. Record review of an admission Record for Resident #58 dated 8/26/2026 indicated he was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of senile degeneration of the brain (a decline in memory that can affect thinking and behavior), dementia (loss of memory that can interfere with daily life), and hypertension (high blood pressure). He discharged home on 8/21/2026.Record review of an admission MDS Assessment for Resident #58 dated 8/6/2026 indicated he had a Medicare Part A stay with a severe impairment in thinking with a BIMS score of 0. Record review of a baseline care plan for Resident #58 dated 7/30/2026 indicated his initial admission/discharge goals included skilled and long-term care. Therapy services included physical and occupation therapy. Record review of a SNF Beneficiary Protection Notification Review for Resident #58 indicated his Medicare Part A skilled services episode start date 7/30/26. His last covered day of part A service was 8/21/26. There was no evidence of an SNF ABN or NOMNC form was given to the resident or family or the Skilled Nursing facility Advanced Beneficiary Notice (SNF ABN) CMS form 10055 was not completed which would have informed Resident #58 of the option to continue services at a private pay rate.During an interview on 8/25/2026 at 9:00 a.m., the BOM said she had not been instructed to give any notices to residents when they discharged from the facility on Medicare services. During an interview on 8/26/2026 at 2:18 p.m., the MDS Coordinator said he was not sure about the process of when a resident was discharged from skilled services and the notices that were to be given to the residents or representatives. He said he knew the forms were given so the resident or representative could have information if they wanted to appeal the decision. He said he started at the facility on 6/15/2026 and was still training in his position as the MDS Coordinator. During an interview on 8/26/2026 at 3:42 p.m., the Administrator had been in the facility since 8/10/2026. She said residents that were no longer skilled with Medicare services should be given a NOMNC form to inform the resident/family that Medicare would no longer pay for services and to notify of the discharge along with their right to appeal the decision. Record review of a facility policy titled Medicare Advanced Beneficiary Notice dated April 2021 indicated, .Residents are informed in advance when changes will occur to their bills. 1. a. The facility issues the Skilled Nursing Facility Advanced Beneficiary Notice (CMS from 10055) to the resident prior to providing care that Medicare usually covers but may not pay for because the care is considered not medically reasonably and necessary, or custodial. b. The resident (or representative) may choose to continue receiving the skilled services that may not be covered, and assume financial responsibility .

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 (Resident #1) residents reviewed for supervision.The facility failed to ensure the secured unit, 900 hall, door alarm and door lock were functioning properly after a fire alarm was triggered on 7/7/2026 at approximately 4:00 p.m. On 7/7/2026 Resident #1 eloped from the facility and was found 0.5 miles from the facility.On 7/21/2026 at 3:45 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 7/22/2026 at 3:28 p.m., the facility remained out of compliance at a severity level of J (immediate jeopardy to resident health or safety) and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.This failure could place residents at risk of harm, serious injuries, and death due to lack of supervision and failure to follow protocols.Findings included: Record review of Resident #1's electronic face sheet, 7/21/2026, indicated Resident #1 originally admitted to the facility on [DATE]. Resident #1's diagnoses included: Major depressive disorder, recurrent severe without psychotic features (an intense and semi-frequent deep feeling of sadness) and Essential Hypertension (high blood pressure).Record review of Resident #1's quarterly MDS assessment, dated 4/29/2026, indicated a BIMS of 6, which indicated severe cognitive impairment. Resident #1 ambulated with no assistance.Record review of Resident #1's care plan, dated 7/7/2026, indicated: The resident is at high risk to wander and resides in the secure unit due to elopement risk. 8/24/24: left facility grounds; 8/30/24: wandering aimlessly in halls with belongings packed; 9/24/24: attempting to open double locked doors on unit; 9/8/24: attempting to go out exit doors on 800 hall; 9/8/24: wandering into hall and other residents rooms with belongings packed exit seeking; 12/10/24: followed hospice CNA off unit, redirection successful. interventions included: Date initiated 8/26/2024, target date 9/1/2026.:Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book.Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate.Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes.Record review of Resident #1's elopement risk assessment, dated 5/18/2026, indicated an elopement score of 11 which was high risk to wander.Record review of Resident #1's elopement risk assessment, dated 7/7/2026, indicated an elopement score of 14 which was high risk to wander.Record review of the progress notes for Resident #1, dated 7/7/2026 at 6:12 a.m. completed by LVN A indicated: Resident walking and talking to self this morning, delusional saying I'm looking out window at RP and placing personal items at door as if he was going out on pass and mumbling to himself, report from off going nurse that he has been doing this all night and going to and from his room to exit doors. Resident placed on 15 minute observation checks for 72 hours.Record review of the progress notes for Resident #1 dated 7/7/26 at 7:20 a.m. completed by LVN A indicated: Resident kicked his leg high enough to hit glass on secure door entrance in front of nurses stated. When told not to do that he made a grumbling noise and turned and went to his room then turned around and came back up hallway. I (LVN A) talked with him and asked what was wrong and he stated I just wanted to see if I could kick that high. I (LVN A) asked Resident please don't do that because he could fall and injure self or someone else, and he states OK and went down the 800 hall and sat in dining room for breakfast.Record review of the progress notes for Resident #1 dated 7/7/2026 at 9:21 a.m. completed by LVN A indicated, Resident given PRN for restless, Ativan Psych N.P. as ordered for behavior and kept repeating that he wanted to leave and calling RP looking out window wanting her to come and pick him up.Progress Note dated 7/7/2026 at 9:36 a.m. completed by LVN A indicated: R.P. called and was given info. that resident is exit seeking and has been prescribed Ativan and to go out for evaluation at behavioral facility and she stated he started this yesterday, the Nurse last Night called and resident up and down and wanted R.P. to come get him, so I talked to him, and she gave consent to send resident to behavioral hospital.Record review of the progress notes for Resident #1 dated 7/7/2026 at 9:49 a.m. completed by LVN A indicated: behavioral hospital sent info and called regarding placement for resident due to mood, Behavior of looking out glass door and yelling out I want to go home and that R.P. was going to come get him, resident placed on 15 minute. observation this morning at 0715 will continue to observe for change.Record review of Psychiatric Nurse Practitioner Psychiatry note for Resident #1 dated 7/7/2026 at 2:41 p.m. completed by NP indicated: The patient experienced an acute behavioral decompensation this morning and last night on the secure unit characterized by overnight agitation, yelling, exit-seeking behavior, and attempted aggression toward the secure-unit door, prompting emergency escalation and an order for transfer to an inpatient psychiatric facility. recent aggression and exit-seeking behavior indicate ongoing short-term safety risk requiring close monitoring and higher level of care evaluation. Environmental disruption was noted on the unit due to renovation and restricted access to his usual seating area, which may be contributing to frustration and dysregulation. Hold disposition (temporarily delay determination of a future plan) to an inpatient psychiatric facility due to de-escalation of acute change in condition with physical aggression on the secure unit. Start lorazepam 1 mg every 12 hours as needed for increased agitation for 14 days, then discontinue. Continue every 15 minute monitoring for 24 hours due to recent behavioral disturbance and safety concerns. Record review of the progress notes for Resident #1 dated 7/7/2026 at 4:53 p.m. completed by the ADM indicated: This writer was notified by HR/BOM that resident was seen outside of facility on Highway 94. Housekeeper notified her supervision at 4:50pm she seen him and was asked to remain with resident she was able to get resident to ride with her back to the facility. Resident returned to facility around 5:00pm with staff. Resident was assessed for injury no injuries noted. Placed one on one and referral sent to outpatient behavioral for increase in exit seeking. Cameras were reviewed and resident was noted to walk out of the double doors on secured unit at 4:33pm prior to this he was sitting in a chair across from nurses station on the unit. Staff checked the doors to ensure they were secure at 4:55pm, doors were secure and alarming. Elopement assessment completed for residents. Resident went out on pass with family this weekend on 7/4/2026.While completing safety assessments resident was heard telling staff that he needed to go to the store and he was out of cigarettes.Record review of the progress notes for Resident #1 dated 7/7/2026 at 6:36 p.m. completed by the DON indicated: This nurse assessed resident upon return to facility. No signs or symptoms of distress or discomfort noted. No injuries noted, resident calm, no mood/behavior issues noted at this time. Resident blood pressure- 143/77 Heart Rate-70 Temperature-97.8 oxygen saturation 96% on room air. Resident currently on 1 on 1 supervision. Resident currently awaiting further psychiatric evaluation. Record review of weather.com, a website to give current and past weather conditions for a given area, showed that the temperature in [NAME], Texas, [NAME] County at the time of the elopement on 7/7/2026 at 4:33 p.m. was in the mid 90 degree Fahrenheit range.Record review of maps.google.com, a website used to track distance by driving or walking from one location to another, showed that the distance of the facility to the location where Resident #1 was located was approximately 0.5 miles and required the resident to cross a busy highway where speeds were recorded from 45 miles per hour to 55 miles per hour.Record review of video clip persevered and provided by the former ADM and recorded from her phone of the video monitor. There were no time and date visible on the video clip. It shows CNA B entering a code and walking off the secured unit with Resident #1 seated in a chair across from the door. Approximately 3 minutes later Resident #1 is seen going to his room, grabbing his belongings and setting them by the door. After a moment he looks around, picks up his belongings and exits the door without entering a code. LVN A is visible through the glass of the nurses' station approximately two feet from the door. During an interview on 7/20/2026 at 12:00 p.m., the BOM said she was the Business Office Manager who was reviewing video with the ADM on 7/7/26 when Resident #1 returned to the facility. She said Resident #1 did not hit any buttons to enter a code and that he simply walked through the door of the secured unit with LVN A and the NP sitting at the desk a few feet away. She said that the assigned nurse to the unit was LVN A and she was responsible for ensuring that the doors on the unit remain secure during her shift. She said that she was not aware of any policy or protocol changes that took place after the incident.During an interview on 7/20/2026 at 12:15 p.m., the DON said when a fire alarm goes off (as it was on 7/7/2026 at around 4:00 p.m.) the fire break doors in the facility were to be closed and a designee begins looking for any fires or issues in the building and that it is typically one person on each end of the building. She said that for the secured unit staff have been trained and should have been aware that the doors unlock when the fire alarm goes off and that the unit nurse is responsible for ensuring each exit is locked and secure to prevent an elopement. She said that the unit nurse has the key to reengage the locks on the secure unit. She said that on the date that Resident #1 eloped LVN A was observed on surveillance video locking one of the double doors but did not lock the inside lock on the unit which left the door unsecure. She said that at around 4:50 p.m. on 7/7/26 the housekeeping supervisor, received a call from HSK, and they were with Resident #1 at the feed store down the road off the highway. She said that when Resident #1 returned to the facility he was placed on one to one supervision as he awaited placement at a behavioral facility to help adjust his medication and get to a stable level. She said that when Resident #1 eloped LVN A was sitting at the desk outside the door along with the NP. She said that if LVN A had followed protocol the elopement would not have occurred. She said that there were always two CNAs on the secured unit and during the elopement, CNA C, was at the end of the 800 hallway with the other residents and was assigned 15 minute checks for Resident #1. She said after the elopement staff on both ends of the facility were in-serviced on elopement and their responsibility in supervising residents, safe surveys were completed for residents on the secured unit. She said that CNA C was transferred to the other end of the facility as a result of the incident as well as having a disciplinary referral in her file. She said that CNA B does not have a prior disciplinary history and was allowed to remain on the secured unit, but she received a disciplinary referral in their file. She said that LVN A received a counseling note in her file and was transferred to the North end of the facility but said she would not do that and resigned. During an interview on 7/20/2026 at 2:00 p.m., former Maintenance Supervisor said that she was working at the facility on 7/7/2026 and her last day working at the facility was 7/10/2026. She said that each morning when she worked she would go to each of the exits of the secured unit to verify that they were locked and that the alarms were functioning. She said that she carried a key for the magnetic locks on the interior doors to the secured unit and would respond when a fire alarm was triggered to see the location of the fire and reset the alarm doors on the secured units once the all clear was given. She said that the nurse was responsible for ensuring the doors were locked throughout their shift and to notify the maintenance director if there were any issues. She said that she did not know what happened the day that the elopement occurred.During an interview on 7/21/2026 at 10:00 a.m., HSK Supervisor said she received a call around 4:53 p.m. on 7/7/2026 from HSK and that she said she was looking at Resident #1 on the side of the road at the feed store that she passed when she was going home for the day. She said that she instructed HSK to safely transport Resident #1 back to the facility and that HSK did that. She said that was all she knew about the incident.During an interview and observation on 7/21/2026 at 10:15 a.m., CNA B walked to each exit of the secured unit and demonstrated that they were locked and all alarms were working. CNA B stated that she was working on the date of 7/7/26 and is familiar with Resident #1. She stated that that afternoon Resident #1 was placed on 15 minute checks due to an escalation in his exit seeking behavior as he had kicked the door earlier in the day and was saying that his RP was coming to pick him up. She stated that at around 3:30 or 4:00 p.m. the fire alarm was set off by the construction workers and that the alarm went off for less than a minute. She stated that when the fire alarm went off she immediately began looking for any signs of fire or smoke and completing a headcount of the residents and that at that time they were all present. She stated that the fire alarm had been cleared but that she and CNA C, were at each of the outside exits to the unit as they are aware that when the alarm is sounded the doors unlock and have to be relocked by the nurse on duty. She stated that the nurse on duty at that time was LVN A. She stated that she did not see LVN A come onto the unit but that it is the nurses responsibility to ensure that all entrances and exits are secure after the alarm is sounded. She stated that since the alarm was clear, they went back to normal on the unit and at around 4:30 p.m. she was passing out snacks and gave the last snack to Resident #1 who was seated in the chair by the entrance to the unit where he commonly sits. She stated that he appeared calm at that time and that CNA C was currently assigned to complete Resident #1's 15 minute checks. She stated that she entered the code to leave the unit and notified the LVN A and Psychiatric NP sitting outside the unit at the nurses desk that she was going to get more snacks for the unit. She stated that the Psychiatric NP was working on her computer and LVN A was sitting in her chair and she did not know what she was doing but she acknowledged that she understood that she Was leaving the unit. She stated that she was gone for about 5 minutes and she did not notice that Resident #1 was gone when she came back on the unit. She stated that she hit the code to get back in but does not check the door before hitting the code and re-entered the secured unit. She stated that a short time later, a little before 5 they were notified that Resident #1 was located down the street at the feed store. She stated that if she were to discover one of the doors was unlocked she would notify the nurse and have them come lock it back. She stated that the staff treat the fire drills as if they are real fires and go through the steps of posting at the door and counting residents and closing bedroom doors to ensure the fire is contained. During an attempted interview on 7/21/2026 at 10:40 a.m. a phone called was made to CNA C. There was no answer and the call was not returned.During an attempted interview on 7/21/2026 at 10:45 a.m. a phone call was made to LVN A. There was no answer and the call was not returned.During an interview on 7/21/2026 at 4:45 p.m. HSK said that on 7/7/2026 she was driving to her home and saw Resident #1 at the feedstore about a half a mile from the facility on the highway and called her supervisor. She said that her supervisor asked her to bring Resident #1 back to the facility and that she asked Resident #1 to get in her car and he did and she brought him back with no issues. She said that she did not know how he got off the secured unit and does not have any further information about the incident.During an interview on 7/21/2026 at 5:00 p.m., the former ADM said that she was on her way home from the facility on 7/7/2026 and received a call from the BOM who informed her that the HSK had found Resident #1 at the feed store down the road from the facility and was bringing him back. She said that she went back to the facility to begin investigating the matter and that once Resident #1 was back on the secured unit she was reviewing video at the nurse's station to see how he had gotten off the unit. She said that she asked Resident #1 how he had gotten off the unit and he pointed to the door and said through that door and it is still unlocked and that he walked through the door again. She said that she knew then that LVN A had not followed the protocol of ensuring that the doors of the unit were locked during her shift. She said that she did not implement any policy changes after the incident but gave all the involved secured unit staff a disciplinary referral in their file and transferred two of the staff to the North end of the building. She said that LVN A declined that transfer and resigned from the facility. She said that they did a safe survey of the secured unit residents and did elopement risk assessment as well as in-serviced the staff on elopement after the incident. She said her last day at the facility was on 7/10/2026. She said that she would send the video clips that she had preserved but that the actual video surveillance for the facility was only preserved for four days. During an observation and attempted interview on 7/21/2026 at 5:40 p.m., Resident #1 was not able to answer questions appropriately due to cognitive communication deficit. Resident #1 was standing by the exit doors of the secured unit and appeared to be exit seeking as he was pacing by the door as CNA G stood between him and the door. He appeared well groomed and in no apparent distress. He smiled and asked to borrow a pen but walked away when asked questions about the elopement. During an interview on 7/22/2026 at 9:11 a.m., the NP said that she does not remember anything about that day and that she was not watching residents but was documenting her visits at the nurse's station of the secured unit. She said that she does not recall if LVN A got up to secure the doors after the fire alarm went off and does not have any information to share about the incident. She said she no longer works for the facility.Record review of the facility's policy Elopement, dated 05/2017 (updated 5/2026), indicated: It is the policy of this home to provide a systematic approach to searching for a resident who may have left the home and/or home grounds. Establish a monitoring system for resident until flight risk is resolved. Determine what measures can be taken to prevent it from happening again.This was determined to be an Immediate Jeaopardy (IJ) on 7/21/2026 at 3:45 p.m. The DON and BOM were notified. The DON was provided with the IT template on 7/21/2026 at 3:45 p.m.The following plan of removal submitted by the facility was accepted on 7/22/2026 at 12:39 p.m.:Summary of Details which lead to outcomes:On 07/21/2026, an abbreviated survey was initiated at 12:00 p.m. on 7/20/2026. On 07/21/2026, provided an IT Template notification that it has been determined that conditions at the facility constitute immediate jeopardy to the health and safety of the residents. The notification of the immediate jeopardy state as follows: Tag #F689 Free from Accidents/Hazards/Supervision/DevicesFAILURE: The failure of keeping residents free from accidents/hazards/supervision/devices puts residents at risk for continued injury, harm, impairment, or death. Identify residents who could be affected:17 residents Problem 1: The facility failed to provide adequate supervision for Resident #1 who was a high risk for elopement, with a history of elopement and had shown increased wandering/exit seeking behaviors.Resident #1 had severe cognitive impairment.7/07/2026 2:30 p.m. Resident #1 was placed on Q15 minutes checks due to exit seeking behavior (saying his ride is outside, he packed his bag and was watching out the door window)On 7/7/2026 at approximately 4:00 p.m., the fire alarm in the facility sounded causing all secure unit doors to unlock which required them to be manually relocked after the alarm was cleared. LVN A did not re-lock the secured unit, inside entrance door. 07/07/2026 At 4:33 p.m. Resident #1 left the facility through the inside entrance of the secured unit through an unlocked door and was unattended for approximately 20 minutes before being assisted back in the facility by a housekeeping staff who discovered him 0.5 mile away from the facility by a feed store on a 4 lane highway (speed limit was 45 going out of town and 55 mph coming into town). The weather history for the day of the elopement showed outside temperatures in the mid-90s.The facility failed to accurately conduct 15-minute checks on Resident #1 since he was out of the facility for 23 minutes and it took an outside person to alert the facility Resident #1 had eloped.The facility failed to develop and implement policies and procedures to ensure residents were provided appropriate supervision in that they have no policy regarding: *Management of exit seeking behaviors of residents in the secured unit,*Procedures to ensure doors are secure after activation of the fire system,*The nurse did not adequately ensure doors were locked after the all clear was given.*This is the facility's third elopement from the secured unit in less than 12 months.Action Taken: After elopement on 07/07/2026 resident was returned to unit by housekeeping and assessed for injury by nurse working shift. He was placed on one-on-one monitoring until placement to outpatient behavioral hospital. 7/7/2026 CNAS on secured unit checked all doors inside of the unit to ensure they were locked and functioning properly. Interviewed resident to see which door he exited out of, and he showed staff that he exited out of double entrance doors to the unit, at that time nurse locked and secured double doors to the unit. On 7/7/2026 the nurse completed head count to ensure all residents were safe on the unit. On 7/7/2026 staff completed safety assessments on secured unit and elopement/wandering assessments for risk levels. Disciplinary actions were given to staff that were responsible supervising secured unit residents. In-services started on 7/7/2026 with staff for elopement and proper monitoring for residents [NAME] are elopement risk.DON will be conducting the in-services for elopement and proper monitoring for residents for ALL STAFF. The in-service will be completed by Wednesday 7/22/2026 by 2pm. Staff that are off will not be able to clock into the facility until they have been in-serviced.In-services started on 7/21/2026 for all staff reeducation by DON. All Staff must be in-serviced and sign in-services before clocking in for their shift. On 7/21/2026 in-services started for post-fire alarm elopement prevention and response started. The in-service includes immediate post fire alarm procedures,(after all clear conduct unit by unit census, charge nurse must perform an immediate, formal head count on their respective units, re-engage and test the security system, maintenance or designated staff will check every exit door and test the wonder management /elopement system to ensure all alarms are active and report any system failure). missing resident/elopement response, post recovery procedures and preventive maintenance and staff training. On 7/21/2026 in-services started for active wandering & heavy pacing residents 1:1 supervision. In-service includes purpose, policy, residents who may need 1:1 (within arm reach), staff responsibilities, what is to be done during 1:1 (within arm reach) supervision and documentation. During 1:1 (within arm reach) supervision staff will do continuous monitoring to ensure patients safety until psych evaluation or a transfer is completed. Staff that is 1:1 is to provide documentation on patient's mood, behavior and location. While on 1:1 nursing staff will document Q15's on the 1:1 resident. The documentation will be located at each nursing station. DON will re-educate staff on Q15 check and on documentation for Q15 min checks.On 7/21/2026 in-services started for exit-seeking. The in-service includes purpose, learning objectives, what is exit-seeking, residents at risk, common triggers, prevention, communication, what to do if a resident attempts to leave, what to do if a resident is missing and documentation. If resident attempts to leave and or is missing staff is to notify charge nurse immediately and never leave the resident unattended, stay within arm's reach, redirect calmly using reassurance and familiar conversations , offer food, toileting and activities. Then document behavior and interventions. On 7/21/2026 in-service started for monitoring residents' location. In-service includes purpose, policy, staff responsibilities, high risk residents, best practices, what to do if a resident cannot be located and documentation. On 7/21/2026 secured unit policy was updated. On 7/21/2026 in-service will be started with staff to discuss changes to be secured unit policy. The changes include: If an elopement occurs on unit. Staff must find how resident exited the unit once returned safely to the unit. Maintenance should change the code the secured unit to prevent elopement by resident watching staff enter the code to exit. Staff should check all doors that are on secured unit to ensure they are locked and secured after each elopement occurs. The staff should also ensure that all alarms are functioning properly to alert staff if a resident is attempting to elope. All staff will be responsible for implementing these changes.PROCEDURE AFTER FIRE ALARMS AND GENERATOR CHECKSOnce staff is given all clear after fire alarms. Staff must do a head count of all residents to ensure they are all safe and on secured unit. Unit Charge Nurse is responsible for locking all doors after fire alarm sounds.Maintenance or designee must immediately check all doors and alarms on the secured unit to ensure they are locking and functioning properly. Report any issues ASAP to Administrator or designee. During weekend and after hours if maintenance supervisor is not at facility and fire alarm is engaged Charge nurse on secured unit must ensure all doors are locked and functioning properly and document it on the door lock log in a binder at the nurses station. The charge nurse on the unit will ensure the doors have been locked and the MOD (manager on duty) will also sign the door lock log if the fire alarm is engaged on the weekend. If the fire alarm is engaged after hours the charge nurse is to ensure the doors are locked back and have the other charge nurse from North wing sign the door lock log with them. REPORT ANY ISSUES ASAP to Administrator or designee.Monitoring of the POR included the following:During an observation on 7/22/2026 at 3:50 p.m. All exits to the secure unit were locked, and alarms were functioning properly. LVN F was observed at the nurse's station outside of the secured unit and CNA D and CNA E were observed inside of the secured unit.During interviews on 7/22/2026 between 12:39 p.m. and 3:28 p.m. the following staff said they had received in services and were able to verbalize understanding that secured unit nurses must do walking rounds, check door locks and alarms, a head count, there must be 2 staff members on the secured unit at all times, and the revised elopement policy, secured unit policy, elopement policy, proper monitoring for residents, post-fire alarm procedures, missing residents/elopement response, post recovery procedures: HSK, CNA B, LVN F, CNA D, CNA E, LVN F, CNA G, CNA H, CNA J, LVN K, LVN L, DM. This sample of employees included two night CNAs, four day CNAs, one night LVN and three day LVNs.During an observation on 7/22/2026 at 3:50 p.m A sign was observed posted on the time clock that read Read all in-services and sign! If they are not signed by 7/21/2026 you will not clock in at this facility! Mandatory nursing staff in-service 7/24/2026 All nursing staff required to attend.Record review of the facility's in-service, dated 7/7/2026, titled Elopement with 25 employee signatures and noted as an on-going in-service. These signatures included both day and night staff from all departments.Record review of the facility's in-service, dated 7/21/2026, titled Monitoring Residents' Location with 41 employee signatures. These signatures included both day and night staff from all departments.Record review of the facility's in-service, dated 7/21/2026, titled Secured Unit Policy 7/21/2026 with 59 employee signatures. These signatures included both day and night staff from all departments.Record review of the facility's in-service, dated 7/21/2026, titled Post-fire alarm Elopement Prevention and Response with 31 employee signatures. These signatures included both day and night staff from all departments.Record review of the facility's in-service, dated 7/21/2026, titled Residents actively seeking exit are to be 1:1 for 72 hours with 33 employee signatures. These signatures included both day and night staff from all departments.Record review of the facility's in-service, dated 7/21/2026, titled Residents actively wandering or pacing are to be put on 15 minute checks immediately with 33 employee signatures. These signatures included both day and night staff from all departments.Record review of the facility's Secure Unit Policy, dated 7/21/2026, with the following revision added: If an elopement occurs on unit. Staff must find how resident exited the unit once returned safely to the unit. Maintenance should change the code the secured unit to prevent elopement by resident watching staff enter the code to exit. Staff should check all doors that are on secured unit to ensure they are locked and secured after each elopement occurs. The staff should also ensure that all alarms are functioning properly to alert staff if a resident is attempting to elope. All staff will be responsible for implementing these changes.PROCEDURE AFTER FIRE ALARMS AND GENERATOR CHECKSOnce staff given all clear after fire alarms. Staff must do a head count of all residents to ensure they are all safe and on secured unit. Unit Charge Nurse is responsible for locking all doors after fire alarm sounds.Maintenance or designee must immediately check all doors and alarms on the secured unit to ensure they are locking and functioning properly. Report any issues ASAP to Administrator or designee. During weekend and after hours if maintenance supervisor is not at facility and fire alarm is engaged Charge nurse on secured unit must ensure all doors are locked and functioning properly and document it on the door lock log in a binder at the nurses' station. The charge nurse on the unit will ensure the doors have been locked and the MOD (manager on duty) will also sign the door lock log if the fire alarm is engaged on the weekend. If the fire alarm is engaged after hours the charge nurse is to ensure the doors are locked back and have the other charge nurse from North wing sign the door lock log with them. REPORT ANY ISSUES ASAP to Administrator or designee. The DON and BOM were informed the Immediate Jeopardy was removed on 7/22/2026 at 3:28 p.m The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the f

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 11 (Resident #1) residents reviewed for supervision. The facility failed to ensure the secured unit, 800 hall, door alarm and door lock was functioning properly. On 10/30/2025 Resident #1 eloped from the facility and was found in the parking lot. An Immediate Jeopardy (IJ) situation was identified on 12/02/2025. While the IJ was removed on 12/03/2025, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of harm, serious injuries, and death due to lack of supervision and failure to follow protocols.Findings include: Record review of Resident #1's electronic face sheet indicated Resident #1 originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. Resident #1 had diagnoses included: cerebral infarction (stroke with right sided weakness), vascular dementia (decline in cognitive function), schizophrenia (affects thinking, feelings and behaviors), schizoaffective disorder (hallucinations and delusions), and cerebral palsy (affects body movement and muscle coordination). Record review of Resident #1's quarterly MDS assessment, dated 9/28/2025, indicated a BIMS of 15, which indicated no cognitive impairment. Resident #1 used a wheelchair and was not assessed for walking 10 feet due to medical condition or safety concerns. Record review of Resident #1's care plan, dated 8/7/2023, indicated: The resident is an elopement risk. 8/6/2023 resident exited the facility and left premises. Resident was found on highway. 10/30/2025 Resident was found outside by shower tech of facility near an entrance door. interventions included: .5. Monitor resident 1:1. Document wandering behavior and attempted diversional interventions in behavior log. 6. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Every 15-minute monitoring for 72 hours. Record review of Resident #1's elopement risk assessment, dated 9/7/2025, indicated a elopement score of 16 which was high risk to wander. Record review of Resident #1's elopement risk assessment, dated 10/30/2025, indicated a elopement score of 11 which was high risk to wander. Record review of the facility incident report for Resident #1, dated 10/30/2025 at 12:00 PM, completed by LVN A indicated: 2 CNAs reported to this nurse patient was found outside in the facility parking lot. During an observation and interview on 12/01/2025 at 9:20 AM, CNA F pushed the secured unit 800 hall back door and the door opened, and the alarm sounded. She said the nurse had to check all the secured unit doors every day to ensure all the doors were locked and the alarms were functioning properly. She said she did not know why the secured unit 800 hall door was not locked. During an interview on 12/01/2025 at 9:25 AM, LVN E said she was the nurse for the secured unit. She said the nurses on the secured unit were supposed to check all the secured unit doors every shift to ensure they were locked, and all door alarms were functioning properly. She said she checked the secured unit 800 hall door on 12/1/2025 when she got to work at 6:00 AM and it was locked, and the alarm was functioning properly. She said she did not know why the door was unlocked on 12/1/2025 during the state surveyor observation at 9:20 AM. During an interview on 12/1/2025 at 9:35 AM, CNA G said the secured unit 800 hall door was supposed to be locked, with the alarm functioning at all times. She said she did not know why the door was unlocked on 12/1/2025 at 9:20am. During an attempted interview on 12/1/2025 at 9:40 AM, Resident #1 was not able to answer questions appropriately due to cognitive communication deficit. During an interview on 12/1/2025 at 11:30 AM, the DON said 12/1/2025 was her first day working at the facility and did not know anything about the elopement on 10/30/2025 prior to her employment. During an interview on 12/1/2025 at 11:41 AM, the Maintenance Director said she did not know why the secured unit 800 hall door was not locked on 12/1/25 at 9:20 AM, but it was not supposed to be unlocked. She said she checked the secured unit 800 hall door when she got to work on 12/1/2025 and the door was locked. She said she checked all facility doors daily to ensure all door locks and door alarms were functioning properly. She said the secured unit 800 hall door had to be locked from the outside and the key stayed in the lock on the outside of the door. She said she did not know why they kept the key in the lock on the door on the outside, but it had always been kept there since she worked at the facility. She said after Resident #1 eloped, on 10/30/2025, she added another alarm to the fire doors that were on the secured unit 800 hall as an intervention for the elopement. During an interview on 12/1/2025 at 11:50 AM, the Administrator said on 10/30/2025 the nurse for the secured unit was assisting another resident and Resident #1 exited the door on the secured unit 800 hall. She said staff told her they did not hear the alarm on the door going off. She said on the secure unit she had never known staff to turn off the alarms, she said on the other end of the building she had found the other doors alarms were turned off in the past. During an observation and interview on 12/2/2025 at 9:15 AM the State Surveyor walked to the secure unit to enter the code on the keypad to enter the secured unit and there was no light on the keypad indicating that the keypad was working. The secured unit doors were not locked and there was no staff in sight. The nurse for the secured unit was not at the nurse's station. Multiple residents were observed standing by the doors on the inside of the secured unit. At 9:18 AM, CNA B was observed entering the last room on the left of the secured unit 900 hall. At 9:22 AM, Housekeeper H approached the secure unit and attempted to put the code in the keypad. Housekeeper H then went to notify the Maintenance Director the secured unit doors were not working and not locked. Housekeeper H left the secured unit doors unmonitored to go and tell the maintenance director the doors were not functioning. At 9:24 AM, CNA C returned from outside of the facility and entered the secured unit and stood at the door to monitor. LVN A then returned to the nurse's station from outside at 9:43 AM and CNA C told her no one was missing from the secured unit. When the State Surveyor asked CNA C how she knew none of the residents were missing from the unit, since she had not left the doors since returning from outside and CNA C did not answer. Upon further questioning of LVN A, she said she had not been told anyone was going to be working on the secured unit, and the doors would not be functioning properly. LVN A said she asked the Maintenance Director what they were working on and the Maintenance Director just said stuff. LVN A said this had never happened to her before and she was not sure what she was supposed to do but said she could print a census and go and do a head count to make sure all residents were in the secured unit. During an interview on 12/2/2025 at 9:27 AM, CNA B said on 10/30/2025 she did not hear the door alarm when Resident #1 eloped. She said she did not know Resident #1 had eloped until CNA J returned Resident #1 to the secured unit. During an interview on 12/2/2025 at 9:30 AM, CNA C said on the day Resident #1 eloped she did not hear an alarm and did not know how the resident was able to get out of the secured unit 800 hall door. She said she would have been able to hear the alarm if it went off because she was in the secured unit dining room with residents when Resident #1 was returned to the secured unit, by CNA J. During an interview on 12/2/2025 at 9:43 AM, LVN A said on 10/30/2025 she received a call that she had a resident who returned from a behavior facility and was in the parking lot refusing to come into the facility. She said she was outside with the resident for approximately 15 minutes after she was able to get the resident to come into the facility, she was readmitting the resident when 2 CNA's brought Resident #1 down the hall and back to the secured unit and told her they had found him in the parking lot. She said she had 2 CNAs on the secured unit that day and no one had heard the alarm going off that morning. She said the Morning prior to Resident #1 eloping, she and the Maintenance Director both checked the secured unit 800 hall door and it was locked, and the alarm was functioning. She said some mornings she found the secured unit 800 hall door unlocked and the alarm not working when she did her daily check and said she would have to lock the door and reset the alarm. She said it made her wonder if there was a short in the wiring due to her finding the door not functioning properly. During an interview on 12/2/2025 at 10:00 AM, LVN K said on 10/30/2025 she was on her break, and she had gone and got something to eat and came back to the facility to eat in her car in the parking lot. She said she saw Resident #1 sitting in his wheelchair at the end of the secured unit 800 hall on the sidewalk. She said Resident #1 was sitting there for about 15 minutes and she thought a staff member was with him when suddenly Resident #1 unlocked his wheelchair and started rolling across the parking lot. She said CNA J was walking across the parking lot and saw Resident #1 and started running across the parking lot and caught Resident #1 and returned him into the facility. During an interview on 12/2/2025 at 10:10 AM, CNA J said she was taking her trash out and when she was coming back around the side of the building, she saw Resident #1 sitting outside on the sidewalk. She said Resident #1 unlocked the wheels of his wheelchair and started rolling down in the parking lot. She said she intercepted Resident #1 and assisted Resident #1 back into the building near the entrance opposite the secured unit and returned Resident #1 to the secured unit. She said she did not know how long Resident #1 had been outside alone and did not see any injuries on Resident #1. Record review of the facility's secured unit door monitoring log, dated 10/30/2025, indicated the secured unit 800 hall door and alarm were functioning properly. Record review of the facility's policy Elopement, dated 05/2017, indicated: it is the policy of this home to provide a systematic approach to searching for a resident who may have left the home and/or home grounds. Establish a monitoring system for resident until flight risk is resolved. Determine what measures can be taken to prevent it from happening again. This was determined to be an Immediate Jeopardy (IJ) on 12/2/2025 at 1:24 p.m. The facility Administrator and DON were notified. The Administrator was provided with the IJ template on 12/2/2025 at 1:24 p.m. The following plan of removal submitted by the facility was accepted on 12/3/2025 at 12:01 p.m.: Summary of Details which lead to outcomes:On 12/02/2025, an abbreviated survey was initiated at [facility]. On 12/02/2025, a surveyor provided an IJ Template notification that it has been determined that conditions at the facility constitute immediate jeopardy to the health and safety of the residents. Identify residents who could be affected:19 residents Problem 1: The facility failed to provide adequate supervision to prevent Resident #1 from eloping from the secured unit. On 10/30/2025 at approximately 11:56 AM Resident #1 left the facility through the back door of the secured unit and was unattended for approximately 15 minutes before being assisted back in the facility by CNA. On 12/02/2025 at 9:15am, the secured unit doors were observed to be unlocked and not monitored by staff for approximately 7 minutes. Action Taken: After elopement on 10/30/2025 Resident #1 was returned to unit by CNA and assessed for injury by nurse working shift. Resident #1 was placed on monitoring every 15 minutes until risk resolved. After fire contractor was on secured unit working on wires the doors became unsecure and staff not aware.On 12/02/2025 after being made aware of doors being unlocked on secured unit by secured unit nurse, maintenance supervisor checked all doors on the secured unit for alarms and proper functioning. The nurse completed head count to ensure all residents were safe on the unit. In-services started with secured unit staff and other departments to ensure unit remains secure, and residents remain safe. Inservice was started on 12/02/2025 by Administrator. Administrator or designee will in services all employees that work or will work on secured unit will have training prior to starting their shift so they are made aware of changes. Inservice consist of nursing making walking rounds to check the alarms doors for proper functioning at the beginning and end of each shift. Secured unit staff is to always have 2 staff members, CNA must report to nurse when taking break and nurse must inform other nurse on duty when she is on break and inform CNA staff when nurse is taking break and who to contact in cause any issues occur. Administrator in-serviced environmental supervisor on 12/02/2025- laundry staff should be making rounds on secured unit and collecting soiled linen. This allows secured unit staff to remain on secured unit to provide supervision and care to residents. Laundry Staff were in serviced on 12/02/2025 by environmental supervisor. In-services completed by Administrator on 12/2/2025 with maintenance supervisor that she must remain on secured unit any time that maintenance is being done on secured unit and inform staff when maintenance is being done. Check the doors to make sure they remain locked. On 12/02/2025 Administrator started in services with secured unit staff so they are aware the secured unit must always have 2 employees on the secured unit for resident safety. CNAs must report to nurse when taking a break to ensure appropriate staffing is on the secured unit. Nurses must inform other nurses on shift when they are taking their break and make sure the CNAs are aware, so they know who to contact If there are any issues while nurse is on break. In-services will be completed with staff prior to working shift on secured unit. On 12/02/2025 Administrator started in services with secured unit nurses to ensure they are doing walking rounds at the beginning and the end of each shift to check the functioning of alarms and doors. Completing a head count at the beginning and end of each shift and report any issues found immediately. In-services will be completed prior to working shift on secured unit. On 12/02/2025 Administrator and other department managers started Inservice on elopement. Facility must follow policy and procedure regarding elopement. Establish a monitoring system until risk has resolved and assign staff to sit one on one with resident until risk resolved. All nurses will be in serviced over changes to elopement policy and monitoring system prior to working shift. Elopement policy and procedure were revised on 12/02/2025, to state a staff will sit one on one with resident until the risk of elopement has resolved. One on one form has been created, and staff must follow guidelines on monitoring form. Guidelines include staff must always remain within arm's reach, resident must remain in line of sight continuously, document observations every 15 minutes, report any changes in behavior to charge nurse. Administrator started in services with all staff on 12/02/2025 and make sure staff is in serviced prior to starting shift. Monitoring of the POR included the following: During an observation on 12/3/2025 at 1:00 PM all secured unit doors were locked, and alarms were functioning properly. LVN A was observed at the nurse's station outside of the secured unit and CNA B, and CNA C were observed inside of the secured unit. During interviews on 12/3/2025 between 2:15 PM and 3:45 PM the following staff said they had received in services and were able to verbalize understanding that secured unit nurses must do walking rounds, check door locks and alarms, a head count, linen barrels were to be collected by laundry staff, there must be 2 staff members on the secured unit at all times , and the revised elopement policy: HSK/Laundry Supervisor, HSK M, HSK L, CNA C, HSK H, LVN A, Cook, HSK N, DM, CNA O, Dishwasher, RN P, CNA Q, Activity Director, MDS, LVN K, CNA S, DON, ADON, MA T, HSK U, LVN V, CNA B, Maintenance Director, and MA W. Record review of the facility's in-service, dated 12/2/2025, titled Secured unit nurses must do walking rounds checking the alarms and doors to ensure they are functioning properly. 2 nurses must sign off at the beginning and end of each shift with oncoming nurse. Nurses must do a head count at this time as well. Any issues found must be reported immediately. With 14 employee signatures. Record review of the facility's in-service, dated 12/2/2025, titled Laundry-Collecting linen barrels off of secured unit with 5 housekeeping and laundry employee's signatures. Record review of the facility's in-service, dated 12/2/2025, titled Security of secured unit signed by the Maintenance Director. Record review of the facility's in-service, dated 12/2/2025, titled Secured Unit Staff signed by 6 secured unit employees. Record review of the facility's in-service, dated 12/2/2025, titled Elopement signed by 28 facility employees. Record review of the facility's Elopement Policy, dated 05/2017, with the following revision added: Establish a monitoring system for resident until flight risk is resolved- Residents that elope must be placed one on one and staff must sit with this resident until the risk has resolved. While monitoring staff will report any issues to charge nurse. One on One monitoring form must be completed. Resident must remain within arm's reach of staff at all times. Resident must remain in line of sight continuously. Document observations every 15 minutes. The Administrator and DON were informed the Immediate Jeopardy was removed on 12/2/2025 at 1:24 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 3 of 11 residents (Resident #1, Resident #2 and Resident #3) reviewed for abuse and neglect. 1. The facility failed to protect Resident #2 from abuse from Resident #1 on 11/1/2025 when Resident #1 hit Resident #2 twice on the shoulder while cussing him. 2. The facility failed to protect Resident #2 from abuse from Resident #1 on 11/10/2025 when Resident #1 hit Resident #2 on the lower legs while cussing him. 3. The facility failed to protect Resident #3 from abuse from Resident #1 on 11/25/2025 when Resident #1 hit Resident #3 on the right thigh with his fists. The reasonable person concept was applied in determining the psychosocial outcomes. These failures could place residents at risk for severe negative psychosocial outcomes such as fear and anxiety, crying, depression, post-traumatic stress symptoms, and loss of sense of safety in their own home. Findings include: 1. Record review of Resident #1's electronic face sheet indicated Resident #1 was a [AGE] year-old male who originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. Resident #1 had diagnoses which included: cerebral infarction (stroke with right side weakness), vascular dementia (decline in cognitive function), schizophrenia (affects thinking, feelings and behaviors), schizoaffective disorder (hallucinations and delusions), conduct disorder (aggression/impulsivity/lack of remorse characteristics), and cerebral palsy (affects body movement and muscle coordination). Record review of Resident #1's quarterly MDS assessment, dated 9/28/2025, indicated a BIMS of 15, which indicated no cognitive impairment. Resident #1 used a wheelchair and was not assessed for walking 10 feet due to medical condition or safety concerns. Record review of Resident #1's care plan, dated 11/22/2023, indicated: 1. Resident #1 had traumatic brain injury and made statements at times that may be inappropriate with interventions that included: .Redirect Resident when he has inappropriate behaviors. 2. Resident #1 had aggressive behavior toward another resident dated 4/8/2024 with interventions that included: .B. Monitor resident. C. Remove resident from situation . Resident #1's care plan was updated on 11/12/2025 to include the incident that occurred on 11/10/2025. Record review of the facility incident report, dated 11/1/2025 at 3:45 PM, written by LVN E, indicated: Resident #1 rolled by Resident #2 hit him twice on his shoulder. Resident #2 had not said anything to Resident #1 and while he was hitting Resident #2 he was cursing him. Record review of the facility incident report, dated 11/10/2025 at 4:00 PM, written by LVN A, indicated: CNA reported to this nurse the [Resident #1] and [Resident #2] were in a verbal altercation, when [Resident #2] stated to [Resident #1] you want to fight. [Resident #1] hit [Resident #2] with his fist in his legs. Record review of the facility incident report, dated 11/25/2025 at 2:45 PM, written by LVN E, indicated: I heard a little loudness from [Resident #1] voice and when I turned and look out from the nurse's station [Resident #1] was rolling toward [Resident #3] and hit him on his right thigh with his fists while I tried to stop him. The only thing that I saw [Resident #3] was trying to push his fist back to keep [Resident #1] away from him. [Resident #3] appears to be astonished and didn't say anything. During an attempted interview on 12/1/2025 at 9:40 AM, Resident #1 was not able to answer questions appropriately due to cognition. Resident #1 did not have any visible injuries or bruising from the incident. 2. Record review of Resident #2's electronic face sheet indicated Resident #2 was a [AGE] year-old male who originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. Resident #2 had diagnoses which included: severe intellectual disabilities (delayed motor, language, and social accomplishments within the first 2 years of life), schizoaffective disorder (hallucinations and delusions), and cerebral palsy (affects body movement and muscle coordination). Record review of Resident #2's significant change in status MDS assessment, dated 11/10/2025, indicated a BIMS of 03, which indicated severe cognitive impairment. Resident #2 used a wheelchair and was not assessed for walking 10 feet due to medical condition or safety concerns. Record review of Resident #2's care plan, dated 9/23/2024, indicated: Resident #2 received aggressive behavior from another resident with interventions that included: A. Assess resident for injuries. B. Monitor resident. C. Remove resident from situation. During an attempted interview on 12/1/2025 at 2:30 PM, Resident #2 was not able to answer questions appropriately due to cognition. 3. Record review of Resident #3's electronic face sheet indicated Resident #3 was a [AGE] year old male who admitted to the facility on [DATE]. Resident #3 had diagnoses which included: anxiety (feeling of fear, dread, and uneasiness), unspecified dementia (confusion or mild cognitive impairment), and cognitive communication deficit (trouble participating in conversations). Record review of Resident #3's significant change in status MDS assessment, dated 10/8/2025, indicated a BIMS of 00, which indicated severe cognitive impairment. Resident #2 used a wheelchair and was not assessed for walking 10 feet due to medical condition or safety concerns. Record review of Resident #3's care plan, dated 11/18/2025, indicated: Resident #3 had episodes of inappropriate behaviors with interventions which included: 1. Monitor for early warning signs of behavior-approach in calm manner, call by name, remove from unwanted stimuli. 2. Explain procedures, using terms, gestures resident can understand. 6. Give meds per orders, monitor labs, -report results to MD. During an attempted interview on 12/1/2025 at 2:15 PM revealed Resident #3 was not able to answer questions appropriately due to cognition. During an interview on 12/01/2025 at 9:25 AM, LVN E said Resident #1 was aggressive. She said the facility had tried to get multiple behavior hospitals to accept him due to his behaviors, but they would not accept him due to his health status. She said on 11/25/2025 Resident #1 hit Resident #3 while she was trying to hold his wheelchair back to try to separate him from Resident #3. She said all she saw Resident #3 was trying to push Resident #1's fist back to try to keep him from hitting him. She said she brought Resident #1 to the nurse's station and monitored him for a couple of hours and then Resident #1 was placed on every 15-minute monitoring. During an interview on 12/01/2025 at 11:50 AM, the Administrator said Resident #1 had aggressive behaviors. She said at times she went to the secured unit to calm Resident #1 down. She said the facility tried to get Resident #1 accepted to multiple behavior hospitals but no one in the state would accept him. She said she did find a behavior hospital out of state to accept him, but his guardian refused to let Resident #1 go anywhere out of state. The Administrator said since Resident #1's guardian refused to let Resident #1 go out of state she issued Resident #1 a 30-day discharge notice and the 30th day would be 12/12/2025. She said she finally found another nursing facility that had accepted him, and he would be discharged soon. During an interview on 12/02/2025 at 9:43 AM, LVN A said Resident #1 had aggressive behaviors towards other residents in the secured unit. She said Resident #1 at times would beat on the glass walls of the nurse's station. She said on 11/10/2025 Resident #1 and Resident #2 got into a verbal altercation and then Resident #1 hit Resident #2 with his fist on Resident #2's leg. She said she had assessed Resident #2 with no injuries found. During an interview on 12/3/2025 at 1:00 PM, the Administrator said she had found alternate placement for Resident #1 and Resident #1 was being discharged on 12/3/2025. During an interview on 12/3/2025 at 3:05 PM, the DON said she had been employed with the facility for 3 days. She said she began the process of reviewing the facility's policies and training on abuse, neglect and exploitation. She said she expected the staff to recognize the signs of ANE and resident safety was the staff's priority. She said moving forward she expected the staff to ensure resident safety and report any abuse immediately to the administrator who was the current abuse coordinator. She stated she instructed the staff to contact her with any allegations or observations of abuse. She stated she would ensure all staff were educated on the facility's abuse policies and re-education would be done as needed. She stated it was important the residents in the facility were protected and it was all of the staff's responsibility to ensure the residents were free from ANE. Record review of the facility's abuse policy, dated 05/2017, with the last revised date of 11/24/2025, indicated: it is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. Physical abuse: Physical action within the definition of abuse, including, but not limited to, hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. Record review of the facility's resident to resident abuse policy, dated 05/2017, with the last revised date of 11/24/2025, indicated: .Will seek proper placement at another home if the physician, responsible party, and/or interdisciplinary care plan team feel that a resident will be a danger to other residents and/or self.

Based on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 6 of 11 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5 and Resident #6) reviewed for abuse and neglect. The facility failed to protect Resident #1 from abuse when on 9/19/25 Resident # 3 hit Resident #1. The facility failed to protect Resident #5 from abuse when on 9/24/25 Resident # 4 grabbed, pulled, and scratched Resident #5's hand. The facility failed to protect Resident #2 from abuse when on 10/3/25 Resident #6 pushed Resident #2 to the ground, resulting in a lumbar vertebral fracture. The facility failed to protect Resident #1 from abuse when on 10/8/25 Resident #2 punched Resident #1 in the face causing a non-displaced nose fracture.On 10/21/2025 at 12:35 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/22/2025 at 04:30 PM, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.The facility Administrator was notified on 10/21/2025 at 12:35 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time.These failures could place residents at risk for continued abuse, and severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings include:Resident #1:Record review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease (progressive neurodegenerative disorder that affects memory, thinking, and behavior), anxiety (excessive worry, fear, and nervousness), and psychotic disorder with hallucinations (disconnect from reality, may see, hear, smell, taste or feel things that are not there). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 99, which indicated Resident #1 was unable to complete the interview. Resident #1's cognitive skills for daily decision making were severely impaired and never or rarely made decisions.Record review of Resident #1's care plan dated 9/09/2024 revealed Resident #1 had the potential to be physically aggressive with interventions that included: 1. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. 2. Assess and address for contributing sensory deficits. 3. Assess and anticipate residents' needs: food, thirst, toileting needs, comfort level, body positioning, and pain.Record review of Resident #1's progress note dated 9/19/2025 at 10:15 PM written by LVN J indicated Resident #3 hit Resident #1 in the back.Record review of Resident #1's progress note dated 10/08/2025 at 8:48 AM written by LVN C indicated on 9/19/25, Resident #1 was pushing the dining room table while Resident #2 was eating. Resident #2 asked Resident #1 not to push the table. Resident #1 continued to push the table. Resident #2 stood up and started punching Resident #1 in the face. Resident #1 had epistaxis (bleeding from the nose). LVN C notified the DON, Administrator and the Nurse Practitioner and sent Resident #1 to the hospital for x-rays of the face.Record review of Resident #1's progress note dated 10/08/2025 at 12:28 PM written by LVN C indicated she received report from the hospital RN that Resident #1 did have a non-displaced fracture to his nose (also known as a hairline fracture, occurs when the bone cracks but remains aligned without shifting).Record review of an incident report dated 9/19/2025 written by LVN J indicated: CNA reported to this nurse that she was taking [Resident #1] past [Resident #3] when [Resident #3] hit [Resident #1] in the back.Record review of an incident report dated 10/08/2025 at 8:30 AM written by LVN C indicated: This [Resident #1] was sitting at the dining room table across from [Resident #2]. This [Resident #1] was moving the table when [Resident #2] asked him to stop moving the table. This [Resident #1] continued to move the table. [Resident #2] stood up and started hitting [Resident #1] with closed fists.Resident #2:Record review of a facility face sheet dated 10/20/25 for Resident #2 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (progressive neurodegenerative disorder that affects memory, thinking, and behavior) and dementia. Face sheet also indicated a discharge date of 10/8/25 to a psychiatric hospital.Record review of a Quarterly MDS assessment dated [DATE] for Resident #2 indicated a BIMS score of 3, indicating a severe cognitive impairment. He exhibited no behavioral symptoms directed toward others. He was independent with most ADLs. Record review of a comprehensive care plan dated 10/3/25 for Resident #2 indicated he was pushed by another resident on 10/3/25. Record review of an incident report dated 10/3/25 for Resident #2 indicated he was pushed by another resident and landed on the floor on his left side. Resident #2 complained of 10/10 pain to his lower back and sustained a skin tear to the left side of his neck measuring 1.2cm X 0.5cm. He was sent to the emergency room for CT scan. Record review of emergency room records dated 10/3/25 for Resident #2 indicated he received a CT of the head without contrast (a non-invasive imaging procedure used to visualize the brain's structures, including the skull and brain tissue, without the use of contrast agents) and a CT of the cervical spine without contrast. Both were negative for fractures. There was no documentation of Resident #2 receiving a CT for lumbar region.Record review of a nursing progress note dated 10/4/25 at 4:27 pm for Resident #2 read: .Resident up and about to D/R moving very slow and not straighten lower extremities when walking and assisted by staff to walk, PRN Tylenol given and is effective. Neuro's WNL will monitor. and was signed by LVN M.Record review of a nursing progress note dated 10/5/25 at 3:03 pm for Resident #2 indicated he was still experiencing pain and MD was notified. A new order was received for arthritis cream to back and to send to hospital for evaluation. Resident #2 refused to go to hospital. Progress note was signed by LVN M.Record review of a nursing progress note dated 10/6/25 at 8:36 am for Resident #2 indicated he complained of severe pain to lower back and was unable to sit up. Progress note was signed by LVN M.Record review of a nursing progress note dated 10/6/25 at 9:43 am for Resident #2 read: .Resident states he would go to Hosp. (hospital) he is hurting very bad sitting in w/c (wheelchair), [RP name] notified that residents agreed to go in to E.R. @ [hospital name] D/T increased back pain, agreed and states she's on her way she will meet him at E.R. and was signed by LVN M.Record review of a nursing progress note dated 10/6/25 at 3:00 pm for Resident #2 indicated he returned to the facility after ER visit with diagnosis of Vertebral Compression acute Fracture of L2.Record review of emergency room records dated 10/6/25 for Resident #2 indicated he received a CT scan of the lumbar spine without contrast which showed an acute compression fracture of L2. Resident #3:Record review of Resident #3's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease (progressive neurodegenerative disorder that affects memory, thinking, and behavior), anxiety (excessive worry, fear, and nervousness), and bipolar disorder with psychotic features (hallucinations and delusions, during episodes of mania or depression).Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 09, which indicated Resident #3 had moderate cognitive impairment. Record review of Resident #3's care plan dated 4/03/2025 revealed Resident #3 had a mood problem related to the disease process of bipolar disorder with interventions that included: 1. Administer medications per MD order for mood management. 2. Encourage resident to express feelings and verbalize concerns during episodes of mood changes and or increased irritability. Allow adequate time to talk and actively listen in a non-judgmental manner. 3. Observe for and report to nurse any acute episode or complaints of feeling sad, loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/eating habits; change in sleep patterns decreased ability to concentrate; change in ability to make purposeful move.4. Psychiatric/psychological consults as ordered by MD. Record review of incident report dated 9/19/2025 at 8:00 PM completed by LVN J indicated: CNA reported to this nurse that she was walking past [Resident #3] with [Resident #1] when [Resident #3] hit [Resident #1] in the back.Record review of Resident #1's progress note dated 9/19/2025 at 10:30 PM written by LVN J indicated: CNA reported to this nurse that this [Resident #3] had hit [Resident #1] in the back. [Resident #3] was assessed and had no sign of injury. The 2 residents were separated for the night into different rooms, both laying in their own beds, eyes closed, even respirations, no signs or symptoms of discomfort. Notified MD and Administrator of incident and separating the 2 residents for the night. Resident #4:Record review of a facility face sheet dated 10/20/25 for Resident #4 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including bipolar disorder (a mental health condition characterized by extreme mood swings, including emotional highs (mania or hypomania) and lows (depression) and Epilepsy (seizures).Record review of an MDS tab in an electronic medical record for Resident #4 indicated there had been no MDS assessment completed.Record review of a care plan tab in an electronic medical record for Resident #4 indicated there had been no comprehensive care plan completed.Record review of an assessments tab in an electronic medical record for Resident #4 indicated there had been no baseline care plan completed. Record review of an incident report dated 9/24/25 for Resident #4 indicated that Resident #4 grabbed the hand of another resident (Resident #5), pulled on her leaving red marks and a scratch mark. Resident #5:Record review of a facility face sheet dated 10/20/25 for Resident #5 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including type 2 diabetes (uncontrolled blood sugar) and dementia. Record review of a Quarterly MDS assessment dated [DATE] for Resident #5 indicated a BIMS score of 13, indicating intact cognition. She exhibited no behavioral symptoms directed toward others. She required set-up or clean-up assistance with most ADLs. Record review of a comprehensive care plan dated 6/4/25 for Resident #5 indicated she had cognitive impairment related to dementia. Record review of an incident report dated 9/24/25 for Resident #5 read: .Resident came to nurse and showed me her right hand having red streaks and a small scratch on the back of her hand. Resident stated, that crazy man grabbed my hand and scratched me pulling on it and he said f.u. bitch.Resident #6:Record review of a facility face sheet dated 10/20/25 for Resident #6 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder and Schizoaffective disorder, Bipolar Type (a mental health condition characterized by symptoms of both schizophrenia and mood disorders, including episodes of mania and depression).Record review of a Quarterly MDS assessment dated [DATE] for Resident #6 indicated a BIMS score of 3, indicating a severe cognitive impairment. He exhibited no behavioral symptoms directed toward others. He required substantial/maximal assistance with most ADLs. Record review of a comprehensive care plan dated 10/3/25 indicated he initiated aggressive behavior to another resident (pushing) on 10/3/25. Record review of an incident report dated 10/3/25 for Resident #6 indicated he pushed another resident causing the other resident to fall.Record review of a nursing progress note dated 10/3/25 at 7:30 am for Resident #6 indicated he was observed pushing another patient while in the dining room. Progress note was signed by LVN C.During an interview on 10/20/2025 at 9:40 AM the Administrator said she had 24 hours to report abuse to the state agency. She asked after further questioning am I supposed to report abuse within 2 hours? She said she did not have an excuse why she did not report the resident-to-resident altercations within the 2-hour required reporting time frame. She said she did not report the incident with Resident #1 and Resident #2 to the state because neither resident was hurt and she just didn't report it. She said she did not know Resident #1 had a non-displaced fracture to the nose. She said she did not know that she was supposed to complete a 5-day investigation and submit it to the state agency.During an interview on 10/20/25 at 10:20 am Resident # 6 did not recall any incidents where he pushed another resident.During a interview on 10/20/2025 at 10:38 AM, CNA K said on 10/08/2025 she was working on the secure unit. She said Resident #1 was in the dining room at breakfast and was moving the table. She said Resident #3 told Resident #1 to stop moving the table. She said Resident #1 continued to move the table and Resident #3 got up and went over to Resident #1 and started punching him in the face with a closed fist. She said her, the nurse and the other CNA separated Resident #1 and Resident #3, and both residents were sent out to the hospital. She said both residents returned from the hospital and both residents were sent out to the behavioral hospital the same day. She said if a resident-to-resident altercation occurred she would separate the residents and make sure they were safe, then she would notify the nurse and the Administrator of the incident.During an interview on 10/20/25 at 10:43 am Resident #5 did not recall any altercations with any residents where she was injured. During an interview on 10/21/2025 at 3:35 PM, CNA L said Resident #1 and Resident #2 were at the dining room table eating and Resident #1 kept moving the table. She said Resident #2 got up and started punching Resident #1 in the face. She said LVN C stepped in and stopped the altercation. She said if she witnessed a resident-to-resident altercation, she would make sure the residents were safe and then notify the charge nurse.During an interview on 10/21/2025 at 3:44 PM LVN C said on 10/08/2025 she was passing medications in the secure unit. She said Resident #1 and Resident #2 were sitting at the dining room table and Resident #1 was pushing the table. She said Resident #2 asked Resident #1 to stop moving the table and Resident #1 did not stop. She said Resident #2 started punching Resident #1 in the face. She said her and the CNA's separated Resident #1 and Resident #2, and Resident #1 had blood dripping down his face. She said she notified the DON and the Administrator and sent both residents out to the hospital. She said Resident #1 had a non-displaced nose fracture. She said both residents returned from the hospital and then both residents were sent to the behavioral hospital on the same day. She also said Resident #6 was upset because he had just finished getting a shower and was upset because he did not like to shower. She said Resident # 2 had walked past Resident #6 and Resident #6 just pushed Resident #2 down. She said there were no warning signs that indicated Resident #6 was upset. She said the DON and MDS nurse were there and came down to the secure unit. She said the Administrator was not in the facility.During an interview on 10/22/2025 at 10:45 AM, the ADON said she found out about the resident-to-resident altercation between Resident #1 and Resident #2 in the morning meeting the day after the incident occurred. She said the residents were separated and sent to the behavioral hospital. She said she knew the Administrator was supposed to report abuse to the state agency within 2 hours. She said the charges nurses do not normally notify her of resident-to-resident altercations but if they did, she would notify the DON and Administrator of the incident.During an interview on 10/22/2025 at 3:23 PM the DON said the staff usually notified her of resident-to-resident altercations. She said she would ask staff if they had notified the Administrator and if they had not then she would notify the Administrator. She said she immediately notified the Administrator of the altercation with Resident #1 and Resident #2. She said the state agency should be notified within 2 hours of an abuse allegation.The facility Administrator was notified on 10/21/2025 at 12:35 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time.The facility's plan of removal was accepted on 10/22/2025 at 12:46 PM and included:PLAN OF REMOVAL FOR IMMEDIATE JEOPARDYAction Taken:Residents were separated from each and monitored until no further aggressive behaviors were demonstrated. Resident #5, #2 and #1 were referred to behavioral unit for impatient treatment. Resident #2 was sent to ER for evaluation and treatment. Prior to be admitted to inpatient behavior hospital #2 & #1 were sent to ER for evaluation and treatment. No other resident identified. Staff Re-Education: 10/21/2025 Regional Director of Operations educated Administrator and DON on types of abuse and policy to keep all residents free from abuse and neglect. All staff will be re-educated on the facility's Abuse/Neglect Policy by DON, Administrator, department supervisors and nurse manager including identification, prevention, and mandatory reporting requirements in services started on 10/20/25 and will continue all staff must be in serviced before starting their shift. Documentation of re-education and staff signatures were started on 10/21/25 all staff will be in serviced before starting their shift. Staff were instructed to immediately intervene and report any signs of resident-to-resident aggression or abuse to the Administrator and DON immediately. Department heads started safety survey assessments on 10/21/2025 at 1:20pm and will have all safety survey assessments completed by 4:00pm on 10/21/2025 on all residents that could give a response at north nurse's station. 10/21/2025 Secured unit charge nurse contacting family members of residents on secured unit to complete safety survey for residents that have impaired cognition. Administrator will hold Resident council meeting is scheduled for 10/22/2025 to discuss abuse/neglect for residents that would like to attend. All residents that did not attend resident council will be talked to individual by department heads and family will be contacted for residents that have impaired cognition. Medical director notified of IJ in facility on 10/21/2025.Monitoring of the Plan of Removal included the following:Record review of in-service titled Abuse/Neglect Policy-reporting/investigating/Implementing dated 10/21/2025 signed by the DON and Administrator. Record review of in-service titled Abuse and Neglect P&P dated 10/21/2025 signed by the DON and Administrator. Record review of in-service titled Resident Behaviors, De-escalation, & Prevention dated 10/22/2025 signed by 16 employees.Record review of in-service titled Abuse and Neglect Inservice which covered witness statements, and all incidents to be turned into the Administrator and DON dated 10/20/2025 signed by 57 employees.Record review of 61 resident safety surveys completed 10/21/2025 with no concerns for abuse or neglect.Record review of resident council minutes dated 10/22/2025 at 11:12 AM with 11 residents in attendance.During interviews conducted on 10/22/2025 between 3:00 PM and 4:30 PM the following staff were able to verbalize understanding of preventing abuse: Administrator, DON, ADON, SW, CNA A, CNA B, LVN C, Housekeeper D, LVN O, MDS Coordinator, MA E, CNA N, CNA F, LVN G, CNA H, and the Activity Director. On 10/21/2025 at 12:35 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/22/2025 at 4:30 PM, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for 6 of 11 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) reviewed for abuse policies. 1. The facility failed to follow their policy by not reporting abuse within the 2-hour required time frame when on Resident # 3 hit Resident #1, on 9/19/25. The facility did not report the incident to the state agency until 9/22/25. 2. The facility failed to follow their policy by not reporting abuse within the 2-hour required time frame when on Resident # 4 scratched and held Resident #5's hand, on 9/24/25. The facility did not report the incident to the state agency until 9/26/25. 3. The facility failed to follow their policy by not reporting an incident of abuse on 10/8/25 when Resident #2 punched Resident #1 in the face which caused a non-displaced nose fracture. 4. The facility failed to gather written statements for incidents that occurred on 9/19/25, 9/24/25 or 10/8/25, as per facility policy. 5. The facility failed to complete the State Provider Investigation Report (5-day report) for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25 and 10/8/25, per facility policy. 6. The facility failed to review corrective actions for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25, per facility policy. 7. The facility failed to analyze the occurrence to determine what changes, if any, were needed to the policies and procedures to prevent further occurrences for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25, as per facility policy. 8. The facility failed to refer all occurrences to the QAPI committee to be analyzed to determine what change or changes were needed, if any, to the facility's policies and procedures to prevent further occurrences for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25 as per facility policy. An Immediate Jeopardy (IJ) situation was identified on 10/21/2025. While the IJ was removed on 10/22/2025, the facility remained out of compliance at a scope of a pattern with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse which could lead to further abuse and neglect of other residents. Findings included: 1. Record review of Resident #1's electronic face sheet indicated a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease (progressive neurodegenerative disorder that affects memory, thinking, and behavior), anxiety (excessive worry, fear, and nervousness), and psychotic disorder with hallucinations (disconnect from reality, may see, hear, smell, taste or feel things that are not there). Record review of Resident #1's quarterly MDS assessment, dated 06/23/2025, indicated a BIMS score of 99, which indicated Resident #1 was unable to complete the interview. Resident #1's cognitive skills for daily decision making were severely impaired and never or rarely made decisions. Record review of Resident #1's care plan dated 9/09/2024 indicated Resident #1 had the potential to be physically aggressive with interventions which included: 1. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. 2. Assess and address for contributing sensory deficits. 3. Assess and anticipate residents' needs: food, thirst, toileting needs, comfort level, body positioning and pain. Record review of Resident #1's progress note, dated 9/19/2025 at 10:15 PM, written by LVN J, indicated Resident #3 hit Resident #1 in the back. Record review of Resident #1's progress note, dated 10/08/2025 at 8:48 AM, written by LVN C, indicated Resident #1 was pushing the dining room table while Resident #2 was eating. Resident #2 asked Resident #1 not to push the table. Resident #1 continued to push the table. Resident #2 stood up and started punching Resident #1 in the face. Resident #1 had epistaxis (bleeding from the nose). LVN C notified the DON, Administrator and the Nurse Practitioner and sent Resident #1 to the hospital for x-rays of the face. Record review of Resident #1's progress note, dated 10/08/2025 at 12:28 PM, written by LVN C, indicated she received report from the hospital RN that Resident #1 had a non-displaced fracture to his nose. Record review of an incident report, dated 9/19/2025, written by LVN J, indicated: CNA reported to this nurse that she was taking [Resident #1] past [Resident #3] when [Resident #3] hit [Resident #1] in the back. Record review of an incident report, dated 10/08/2025 at 8:30 AM, written by LVN C, indicated: This [Resident #1] was sitting at the dining room table across from [Resident #2]. This [Resident #1] was moving the table when [Resident #2] asked him to stop moving the table. This [Resident #1] continued to move the table. [Resident #2] stood up and started hitting [Resident #1] with closed fists. Resident #1 was not able to be interviewed due to Resident #1 being in the behavioral hospital. 2. Record review of Resident #2's facility face sheet, dated 10/20/25, indicated an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Alzheimer's disease and dementia (decline in cognitive abilities such as memory, thinking, and problem solving). Resident #2 was discharges to a psychiatric hospital on [DATE]. Record review of Resident #2's Quarterly MDS assessment, dated 5/27/25, indicated a BIMS score of 3, which indicated a severe cognitive impairment. He exhibited no behavioral symptoms directed toward others. He was independent with most ADLs. Record review of Resident #2's comprehensive care plan, dated 10/3/25, indicated he received aggression on 10/3/25 when he was pushed by another resident. Record review of Resident #2's incident report, dated 10/3/25, indicated he was pushed by another resident and landed on the floor on his left side. Resident #2 complained of 10/10 pain to his lower back and sustained a skin tear to the left side of his neck measuring 1.2cm X 0.5cm. He was sent to the emergency room for CT scan. Record review of Resident #2's emergency room records, dated 10/3/25, indicated he received a CT of the head without contrast and a CT of the cervical spine without contrast. Both were negative for fractures. There was no documentation of Resident #2 receiving a CT for the lumbar region. Record review of Resident #2's nursing progress note, dated 10/4/25 at 4:27 PM, for indicated: .Resident up and about to D/R moving very slow and not straighten lower extremities when walking and assisted by staff to walk, PRN Tylenol given and was effective. Neuro's WNL will monitor. signed by LVN M. Record review of Resident #2's nursing progress note, dated 10/5/25 at 3:03 PM, indicated Resident #2 was still experiencing pain and the MD was notified. New order was received for arthritis cream to back and to send to hospital for evaluation. Resident #2 refused to go to the hospital. Progress note was signed by LVN M. Record review of Resident #2's nursing progress note, dated 10/6/25 at 8:36 AM, indicated he complained of severe pain to the lower back and was unable to sit up. The progress note was signed by LVN M. Record review of Resident #2's nursing progress note, dated 10/6/25 at 9:43 AM, indicated: .Resident states he would go to Hospital. he is hurting very bad sitting in w/c [family member] notified that residents agreed to go into E.R. at [hospital name] D/T increased back pain, [family member] agreed and states she's on her way she will meet him at E.R. signed by LVN M. Record review of Resident #2's nursing progress note, dated 10/6/25 at 3:00 PM, indicated he returned to the facility after ER visit with diagnosis of Vertebral Compression acute Fracture of L2. Record review of Resident #2's emergency room records, dated 10/6/25, indicated he received a CT scan of the lumbar spine without contrast which showed an acute compression fracture of L2. Resident #2 was not able to be interviewed due to Resident #2 currently in the behavioral hospital. 3. Record review of Resident #3's electronic face sheet indicated a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease (progressive neurodegenerative disorder that affects memory, thinking, and behavior), anxiety (excessive worry, fear, and nervousness), and bipolar disorder with psychotic features (hallucinations and delusions, during episodes of mania or depression). Record review of Resident #3's quarterly MDS assessment, dated 07/02/2025, indicated a BIMS score of 09, which indicated Resident #3 had moderate cognitive impairment. Record review of Resident #3's care plan, dated 4/03/2025, indicated Resident #3 had a mood problem related to the disease process of bipolar disorder with interventions which included: 1. Administer medications per MD order for mood management. 2. Encourage resident to express feelings and verbalize concerns during episodes of mood changes and or increased irritability. Allow adequate time to talk and actively listen in a non-judgmental manner. 3. Observe for and report to nurse any acute episode or complaints of feeling sad, loss of pleasure and interest in activities; feelings or worthlessness or guilt; change in appetite/eating habits; change in sleep patterns decreased ability to concentrate; change in ability to make purposeful move.4. Psychiatric/psychological consults as ordered by MD. Record review of Resident #1's progress note, dated 9/19/2025 at 10:30 PM, written by LVN J, indicated: CNA reported to this nurse that this [Resident #3] had hit [Resident #1] in the back. [Resident #3] was assessed and had no sign of injury. The 2 residents were separated for the night into different rooms, both laying in their own beds, eyes closed, even respirations, no signs or symptoms of discomfort. Notified MD and Administrator of incident and separating the 2 residents for the night. Record review of incident report for Resident #3 dated 9/19/2025 at 8:00 PM, completed by LVN J, indicated: CNA reported to this nurse that she was walking past [Resident #3] with [Resident #1] when [Resident #3] hit [Resident #1] in the back. Record review of the state agency reporting system website https://txhhs.my.salesforce.com indicated the facility Administrator reported the resident-to-resident altercation on 9/22/2025 at 2:48 PM which occurred on 9/19/2025 at 8:00 PM. Record review of the state agency reporting system website https://txhhs.my.salesforce.com indicated the facility Administrator did not report the resident-to-resident altercation which occurred on 10/08/2025 at 8:48 AM. During an interview on 10/20/2025 at 10:15 AM, Resident #3 said he never had an altercation with anyone at the facility. 4. Record review of Resident #4's facility face sheet, dated 10/20/25, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included bipolar disorder (extreme mood swings between mania and depression) and Epilepsy (seizures). Record review of Resident #4's MDS tab in the electronic medical record indicated there had been no MDS assessment completed. Record review of Resident #4's care plan tab in the electronic medical record indicated there had been no comprehensive care plan completed. Record review of Resident #4's assessments tab in an electronic medical record indicated there had been no baseline care plan completed with 48 hours of admission. Record review of Resident #4's incident report, dated 9/24/25, indicated Resident #4 grabbed the hand of another resident and pulled on her, leaving red marks and a scratch mark. 5. Record review of Resident #5's facility face sheet, dated 10/20/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes (high blood sugar) and dementia (loss of memory, language, problem solving and other thinking abilities). Record review of Resident #5's Quarterly MDS assessment, dated 9/26/25, indicated a BIMS score of 13, which indicated intact cognition. She exhibited no behavioral symptoms directed toward others. She required set-up or clean-up assistance with most ADLs. Record review of Resident #5's comprehensive care plan, dated 6/4/25, indicated she had cognitive impairment related to dementia. Record review of Resident #5's incident report, dated 9/24/25, indicated: .Resident came to nurse and showed me her right hand having red streaks and a small scratch on the back of her hand. Resident stated, 'that crazy man grabbed my hand and scratched me pulling on it and he said f.u. bitch.' During an interview on 10/20/25 at 10:43 AM, Resident #5 denied any altercations with any residents where she was injured. 6. Record review of Resident #6's facility face sheet, dated 10/20/25, indicated he was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included Major Depressive (feelings of sadness, hopelessness) Disorder, and schizoaffective disorder (combines symptoms of schizophrenia and mood disorders such as depression or mania), Bipolar Type (extreme mood swings between mania and depression). Record review of Resident #6's Quarterly MDS assessment, dated 8/18/25, indicated a BIMS score of 3, which indicated a severe cognitive impairment. He exhibited no behavioral symptoms directed toward others. He required substantial/maximal assistance with most ADLs. Record review of Resident #6's comprehensive care plan, dated 10/3/25, indicated he initiated aggressive behavior to another resident (pushing) on 10/3/25. Record review of Resident #6's incident report, dated 10/3/25, indicated he pushed another resident causing the other resident to fall. Record review of Resident #6's nursing progress note, dated 10/3/25 at 7:30 AM, indicated he was observed pushing another resident while in the dining room. The progress note was signed by LVN C. During an interview on 10/20/25 at 10:20 AM Resident # 6 did not recall any incidents where he pushed another resident. During a interview on 10/20/2025 at 10:38 AM, CNA K said on 10/08/2025 she was working on the secure unit. She said Resident #1 was in the dining room at breakfast and was moving the table. She said Resident #3 told Resident #1 to stop moving the table. She said Resident #1 continued to move the table and Resident #3 got up and went over to Resident #1 and started punching him in the face with a closed fist. She said her, the nurse and the other CNA separated Resident #1 and Resident #3, and both residents were sent out to the hospital. She said both residents returned from the hospital and both residents were sent out to the behavioral hospital the same day. She said if a resident-to-resident altercation occurred she would separate the residents and make sure they were safe, then she would notify the nurse and the Administrator of the incident. During an interview on 10/20/2025 at 11:00 AM, the Administrator said she had 24 hours to report abuse to the state agency. She asked after further questioning am I supposed to report abuse within 2 hours? She said she did not have an excuse why she did not report the resident-to-resident altercations within the 2-hour required reporting time frame. She said she did not report the incident with Resident #1 and Resident #2 to the state survey agency because neither resident was hurt and she just didn't report it. She said she did not know Resident #1 had a non-displaced fracture on the nose. She said she did not know she was supposed to complete a 5-day investigation and submit it to the state agency. The Administrator said she did not know what the 3613A was. She said she had not completed them nor sent in any 5-day investigations to the state agency's reporting website. When asked what the reporting time frame was for abuse, she stated 24 hours. When surveyor further questioned administrator, she asked if it was 2 hours. During an interview on 10/21/2025 at 3:35 PM, CNA L said Resident #1 and Resident #2 were at the dining room table eating and Resident #1 kept moving the table. She said Resident #2 got up and started punching Resident #1 in the face. She said LVN C stepped in and stopped the altercation. She said if she witnessed a resident-to-resident altercation, she would make sure the residents were safe and then notify the charge nurse. During an interview on 10/21/2025 at 3:44 PM, LVN C said on 10/08/2025 she was passing medications in the secure unit. She said Resident #1 and Resident #2 were sitting at the dining room table and Resident #1 was pushing the table. She said Resident #2 asked Resident #1 to stop moving the table and Resident #1 did not stop. She said Resident #2 started punching Resident #1 in the face. She said her and the CNA's separated Resident #1 and Resident #2, and Resident #1 had blood dripping down his face. She said she notified the DON and the Administrator and sent both residents out to the hospital. She said Resident #1 had a non-displaced nose fracture. She said both residents returned from the hospital and then both residents were sent to the behavioral hospital on the same day. LVN C said Resident #6 was upset because he had just finished getting a shower and was upset because he did not like to shower. She said Resident # 2 walked past Resident #6 and Resident #6 and pushed Resident #2 down. She said there were no warning signs that indicated Resident #6 was upset. She said the DON and MDS nurse were there and came down to the secure unit. She said the Administrator was not in the facility. She said if there was a resident-to-resident altercation she would make sure the residents were safe then she would notify the DON and the Administrator. During an interview on 10/22/2025 at 10:45 AM, the ADON said she found out about the resident-to-resident altercation between Resident #1 and Resident #2 in the morning meeting the day after the incident occurred. She said the residents were separated and sent to the behavioral hospital. She said she knew the Administrator was supposed to report abuse to the state agency within 2 hours. She said the charges nurses do not normally notify her of resident-to-resident altercations but if they did, she would notify the DON and Administrator of the incident. During an interview on 10/22/2025 at 3:23 PM, the DON said the staff usually notified her of resident-to-resident altercations. She said she would ask staff if they notified the Administrator and if they had not then she would notify the Administrator. She said she immediately notified the Administrator of the altercation with Resident #1 and Resident #2. She said the state agency should be notified within 2 hours of an abuse allegation. Record review of the facility's policy titled Resident to Resident Abuse, dated May 2017, indicated: .2. The Administrator will: 1. Notify state agency as required. 2. Notify local law enforcement as required . This was determined to be an Immediate Jeopardy (IJ) on 10/21/2025 at 12:35 PM. The facility Administrator was notified. The Administrator was provided with the IJ template on 10/21/2025 at 12:35 PM. The following plan of removal submitted by the facility was accepted on 10/22/2025 at 2:54 PM: Summary of Details which lead to outcomes:On 10/20/2025 a complaint survey was initiated at the facility. On 10/21/2025 a surveyor provided an IJ Template notification that it has been determined that conditions at the facility constitute an immediate jeopardy to the health and safety of the residents. The notification of the immediate jeopardy state as follows: Tag #Tag: F607 - Development/Implementation of Abuse Policy FAILURE: The failure to keep residents free from abuse or neglect related to not developing or implementing the abuse policy and this puts residents at risk for serious injury, harm, impairment, or death from abuse allegations and delays in reporting abuse allegations and delays in reporting abuse allegations to the abuse coordinator to implement preventative measures. Identify residents who could be affected:All residents Problem 1: The facility failed to develop and implement policies to investigate, prevent and report incidents for resident abuse. The facility failed to develop and implement policies to investigate, prevent, and report incidents of staff to resident abuse. The facility failed to follow their policy by not reporting abuse within the 2 hour required time frame when on 9/19/25 Resident [TF36] # 3 hit Res #1. The facility did not report the incident to the state agency until 9/22/25.The facility failed to follow their policy by not reporting abuse within the 2 hour required time frame when on 9/24/25 Res # 4 scratched and held Res #5's hand. The facility did not report the incident to the state agency until 9/26/25.The facility failed to follow their policy by not reporting an incident of abuse on 10/8/25 when Res #2 punched Res #1 in the face causing a non-displaced nose fracture.The facility failed to gather written statements for incidents that occurred on 9/19/25, 9/24/25, or 10/8/25 as per facility policy.The facility failed to complete the State Provider Investigation Report (5-day report) for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25 as per facility policy. The facility failed to review corrective actions for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25 as per facility policy.The facility failed to analyze the occurrence to determine what changes, if any, are needed to the policies and procedures to prevent further occurrences for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25 as per facility policy.The facility failed to refer all occurrences to QAPI committee to be analyzed to determine what change or changes are needed, if any, to the facilities policies and procedures to prevent further occurrences for incidents of resident-lo-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25 as per facility policy. Action Taken: Residents had interventions put in place including separation from other residents when resident to resident altercations occurred. Resident #4 was separated from Resident #5, referral sent to behavioral inpatient for Resident #4 resident admitted to behavioral inpatient on 9/25/2025. Resident #6 and Resident #2 were separated from one another. Both Resident #6 & Resident #2 were sent to the ER for evaluation and treatment. Once returned both were placed on monitoring until no signs of behavior were noted. Resident #2 & Resident #1 were separated from one another and both sent to ER, while in ER staff made referral to impatient behavioral hospital. Both Residents #2 & #1 were admitted to inpatient behavioral hospital.Abuse reportable events policy was reviewed and revised on 10/21/2025 to include steps for reporting, documentation required and time to report events. Abuse/neglect in services were started with all staff on 10/21/2025 by the Administrator, the DON, nurse managers and department supervisors, all employees must be educated before working their scheduled shift. Social Services in serviced Administer on 10/20/2025 to complete safety surveys with each incident especially any allegations of abuse/neglect to ensure residents feel safe in the facility and they have not experienced any negative events. The DON and Nurse manager assigned to educate nurse on documentation related to incidents, including incident reports, witness statements, progress notes, monitoring logs and head to toe skin assessments. Per facility policy charge nurse will be the staff member that begins taking written statements after the allegation is reported to the Administrator and DON. 10/20/2025 safety surveys started by department heads for residents that could answer survey questions, secured unit charge nurse contacting family members for residents on the secured unit with impaired cognition. Resident council meeting scheduled for residents on 10/22/2025. 10/22/2025 to discuss revision to policy including the steps to reporting and the required documentation that was needed for completing an investigation related to an incident that occurred and was a reportable event. Department heads would speak to resident's individually that did not attend the meeting and call family members with residents that have impaired cognition. The Administrator would be completing the meeting with residents. The Regional director of operations in serviced the DON and Administrator on revision to policy on abuse/neglect allegations. Policy only stated notify state agency as required. The revision now has specific contact information with multiple methods of notification including email, phone, and TULIP. Multiple methods on how to submit 3613 investigation report including email, TULIP, and fax. No other incidents were found at this time. Regional Director of operations visited the facility on a monthly basis and would follow up with the Administrator/DON with each self-report to ensure the investigation of self-reports were completed in timely manner and 3613 was submitted to state with all the documentation gathered with investigation. All communication between monthly visits were to be sent through email. The Nurse manager started Inservice with nurses to 10/21/2025 to discuss Documentation including incident reports, witness statements, skin assessments, treatments for injuries, interventions that were put in place to protect the residents, in services to help prevent incident from further occurring, monitoring documentation, any hospital records, safety surveys and any additional information that was required for investigation. Inservice was related to having more thorough assessment and appropriate documentation in place. In-services would be completed before staff worked the next shift. Monitoring: The facility's Abuse Reportable events Policy was reviewed and revised on 10/21/25 to clarify timelines for internal/external reporting and investigation steps.The revised policy was approved by the Governing Body and redistributed to all departments. Future new hires will receive abuse prevention and reporting training during orientation before working any shift.The DON or designee will initiate and complete all abuse investigations within five days using the state-approved Form 3613-A process.All investigations will be reviewed and signed by the Administrator for accuracy and timeliness before submission.The Administrator or DON will audit all incident reports weekly for 90 days to ensure proper reporting, investigation, and documentation.Results will be presented to the QA Committee monthly for review and any needed corrective actions.The QA Committee will evaluate compliance and determine if further education or policy revisions are needed. Monitoring of the POR included the following: Record review of inservice, dated 10/20/2025, titled Safety Surveys after abuse/neglect allegation which indicated random safety surveys must be completed after each abuse/neglect allegation signed by the SW . Record review of inservice, dated 10/21/2025, titled Documentation requirements for incidents which indicated all incident reports require the following documentation: head to toe assessments, progress notes, witness statements, monitoring log for behaviors, treatment orders for injuries, completed incident reports, and requested hospital documentation signed by 24 employees. Record review of 61 resident safety surveys completed 10/21/2025 documented no concerns for abuse or neglect. Record review of resident council minutes, dated 10/22/2025 at 11:12 AM, with 11 residents in attendance. Record review of inservice titled Form 3613 Quick Reference & Staff Training Guide, dated 10/21/2025, signed by the DON and Administrator. Record review of inservice titled Abuse and Neglect P&P, dated 10/21/2025, signed by the DON and Administrator. Record review of inservice titled Abuse/Neglect Policy-reporting/investigating/Implementing, dated 10/21/2025, signed by the DON and Administrator. During interviews conducted on 10/22/2025 between 3:00 PM and 4:30 PM the following staff were able to verbalize understanding of developing and implementing the facilities abuse policy: Administrator, DON, ADON, SW, CNA A, CNA B, LVN C, Housekeeper D, LVN O, MDS Coordinator, MA E, CNA N, CNA F, LVN G, CNA H, and the Activity Director. The Administrator was informed the Immediate Jeopardy was removed on 10/22/2025 at 4:30 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review the facility failed to ensure, in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility had evidence that all alleged violations were thoroughly investigated and prevented further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 6 of 11 residents (Residents #1, Resident #2, Resident #3, Resident #4, Resident #5 and Resident #6) reviewed for abuse/neglect. 1.The facility failed to investigate abuse when Resident # 3 hit Resident #1, on 9/19/25. 2. The facility failed to investigate abuse when Resident # 4 grabbed, pulled, and scratched Resident #5's hand, on 9/24/25. 3. The facility failed to investigate abuse when Resident #6 pushed Resident #2 to the ground, on 10/3/25. 4. The facility failed to investigate abuse when Resident #2 punched Resident #1 in the face which caused a non-displaced nose fracture, on 10/8/25. 5. The facility failed to gather written statements for incidents that occurred on 9/19/25, 9/24/25, or 10/8/25 as per facility policy. 6. The facility failed to complete the State Provider Investigation Report (5-day report) for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25 as per facility policy. 7. The facility failed to review corrective actions for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25 as per facility policy. 8. The facility failed to analyze the occurrence to determine what changes, if any, are needed to the policies and procedures to prevent further occurrences for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25 as per facility policy. An Immediate Jeopardy (IJ) situation was identified on 10/21/2025. While the IJ was removed on 10/22/2025, the facility remained out of compliance at a scope of a pattern with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for abuse, physical harm, psychosocial harm, trauma, unrecognized abuse and emotional distress.Findings Included: 1.Record review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included alzheimers disease (progressive neurodegenerative disorder that affects memory, thinking, and behavior), anxiety (excessive worry, fear, and nervousness), and psychotic disorder with hallucinations (disconnect from reality, may see, hear, smell, taste or feel things that are not there). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 99, which indicated Resident #1 was unable to complete the interview. Resident #1's cognitive skills for daily decision making were severely impaired and never or rarely made decisions. Record review of Resident #1's care plan dated 9/09/2024 revealed Resident #1 had the potential to be physically aggressive with interventions that included: 1. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. 2. Assess and address for contributing sensory deficits. 3. Assess and anticipate residents' needs: food, thirst, toileting needs, comfort level, body positioning, and pain. Record review of Resident #1's progress note dated 9/19/2025 at 10:15 PM written by LVN J indicated Resident #3 hit Resident #1 in the back. Record review of Resident #1's progress note dated 10/08/2025 at 8:48 AM written by LVN C indicated Resident #1 was pushing the dining room table while Resident #2 was eating. Resident #2 asked Resident #1 not to push the table. Resident #1 continued to push the table. Resident #2 stood up and started punching Resident #1 in the face. Resident #1 had epistaxis (bleeding from the nose). LVN C notified the DON, Administrator and the Nurse Practitioner and sent Resident #1 to the hospital for xrays of the face. Record review of Resident #1's progress note dated 10/08/2025 at 12:28 PM written by LVN C indicated she received report from the hospital RN that Resident #1 did have a non-displaced fracture to his nose. Record review of an incident report dated 9/19/2025 written by LVN J indicated: CNA reported to this nurse that she was taking [Resident #1] past [Resident #3] when [Resident #3] hit [Resident #1] in the back. Record review of an incident report dated 10/08/2025 at 8:30 AM written by LVN C indicated: This [Resident #1] was sitting at the dining room table across from [Resident #2]. This [Resident #1] was moving the table when [Resident #2] asked him to stop moving the table. This [Resident #1] continued to move the table. [Resident #2] stood up and started hitting [Resident #1] with closed fists. Resident #1 was not able to be interviewed due to Resident #1 currently in the behavioral hospital. 2. 2. Record review of Resident #2's facility face sheet, dated 10/20/25, indicated an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Alzheimer's disease and dementia (decline in cognitive abilities such as memory, thinking, and problem solving). Resident #2 was discharges to a psychiatric hospital on [DATE]. Record review of a Quarterly MDS assessment dated [DATE] for Resident #2 indicated a BIMS score of 3, indicating a severe cognitive impairment. He exhibited no behavioral symptoms directed toward others. He was independent with most ADLs. Record review of a comprehensive care plan dated 10/3/25 for Resident #2 indicated he received aggression on 10/3/25 when he was pushed by another resident. Record review of an incident report dated 10/3/25 for Resident #2 indicated he was pushed by another resident and landed in the floor on his left side. Resident #2 complained of 10/10 pain to his lower back and sustained a skin tear to the left side of his neck measuring 1.2cm X 0.5cm. He was sent to the emergency room for CT scan. Record review of emergency room records dated 10/3/25 for Resident #2 indicated he received a CT of the head without contrast and a CT of the cervical spine without contrast. Both were negative for fractures. There was no documentation of Resident #2 receiving a CT for the lumbar region. Record review of a nursing progress note dated 10/4/25 at 4:27 pm for Resident #2 read: .Resident up and about to D/R moving very slow and not straighten lower extremities when walking and assisted by staff to walk, PRN Tylenol given and is effective. Neuro's WNL will monitor. and was signed by LVN M. Record review of a nursing progress note dated 10/5/25 at 3:03 pm for Resident #2 indicated he was still experiencing pain and MD was notified. A new order was received for arthritis cream to back and to send to hospital for evaluation. Resident #2 refused to go to hospital. Progress note was signed by LVN M. Record review of a nursing progress note dated 10/6/25 at 8:36 am for Resident #2 indicated he complained of severe pain to lower back and was unable to sit up. Progress note was signed by LVN M. Record review of a nursing progress note dated 10/6/25 at 9:43 am for Resident #2 read: .Resident states he would go to Hosp. he is hurting very bad sitting in w/c, notified that residents agreed to go in to E.R. @ [hospital name] D/T increased back pain, wife agreed and states she's on her way she will meet him at E.R. and was signed by LVN M. Record review of a nursing progress note dated 10/6/25 at 3:00 pm for Resident #2 indicated he returned to the facility after ER visit with diagnosis of Vertebral Compression acute Fracture of L2. Record review of emergency room records dated 10/6/25 for Resident #2 indicated he received a CT scan of the lumbar spine without contrast which showed an acute compression fracture of L2. 3. Record review of Resident #3's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease (progressive neurodegenerative disorder that affects memory, thinking, and behavior), anxiety (excessive worry, fear, and nervousness), and bipolar disorder with psychotic features (hallucinations and delusions, during episodes of mania or depression). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 09, which indicated Resident #3 had moderate cognitive impairment. Record review of Resident #3's care plan dated 4/03/2025 revealed Resident #3 had a mood problem related to the disease process of bipolar disorder with interventions that included: 1. Administer medications per MD order for mood management. 2. Encourage resident to express feelings and verbalize concerns during episodes of mood changes and or increased irritability. Allow adequate time to talk and actively listen in a non-judgmental manner. 3. Observe for and report to nurse any acute episode or complaints of feeling sad, loss of pleasure and interest in activities; feelings or worthlessness or guilt; change in appetite/eating habits; change in sleep patterns decreased ability to concentrate; change in ability to make purposeful move.4. Psychiatric/psychological consults as ordered by MD. Record review of Resident #1's progress note dated 9/19/2025 at 10:30 PM written by LVN J indicated: CNA reported to this nurse that this [Resident #3] had hit [Resident #1] in the back. [Resident #3] was assessed and had no sign of injury. The 2 residents were separated for the night into different rooms, both laying in their own beds, eyes closed, even respirations, no signs or symptoms of discomfort. Notified MD and Administrator of incident and separating th 2 residents for the night. Record review of incident report dated 9/19/2025 at 8:00 PM completed by LVN J indicated: CNA reported to this nurse that she was walking past [Resident #3] with [Resident #1] when [Resident #3] hit [Resident #1] in the back. Record review of the state agency reporting system website https://txhhs.my.salesforce.com indicated the facility Administrator reported the resident-to-resident altercation on 9/22/2025 at 2:48 PM that occurred on 9/19/2025 at 8:00 PM. Record review of the state agency reporting system website https://txhhs.my.salesforce.com indicated the facility Administrator did not report the resident-to-resident altercation that occurred on 10/08/2025 at 8:48 AM. During an interview on 10/20/2025 at 10:15 AM Resident #3 said he had never had an altercation with anyone at the facility. 4. Record review of a facility face sheet dated 10/20/25 for Resident #4 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including bipolar disorder (extreme mood swings between mania and depression) and Epilepsy (seizures). Record review of an MDS tab in an electronic medical record for Resident #4 indicated there had been no MDS assessment completed. Record review of a care plan tab in an electronic medical record for Resident #4 indicated there had been no comprehensive care plan completed. Record review of an assessments tab in an electronic medical record for Resident #4 indicated there had been no baseline care plan completed with 48 hours of admission. Record review of an incident report dated 9/24/25 for Resident #4 indicated that Resident #4 grabbed the hand of another resident, pulled on her leaving red marks and a scratch mark.5. Record review of a facility face sheet dated 10/20/25 for Resident #5 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including type 2 diabetes (high blood sugar) and dementia (loss of memory. Language, problem solving and other thinking abilities). Record review of a Quarterly MDS assessment dated [DATE] for Resident #5 indicated a BIMS score of 13, indicating intact cognition. She exhibited no behavioral symptoms directed toward others. She required set-up or clean-up assistance with most ADLs. Record review of a comprehensive care plan dated 6/4/25 for Resident #5 indicated she had cognitive impairment related to dementia. Record review of an incident report dated 9/24/25 for Resident #5 read: .Resident came to nurse and showed me her right hand having red streaks and a small scratch on the back of her hand. Resident stated, that crazy man grabbed my hand and scratched me pulling on it and he said f.u. bitch.During an interview on 10/20/25 at 10:43 am Resident #5 denied any altercations with any residents where she was injured. 6. Record review of a facility face sheet dated 10/20/25 for Resident #6 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder (feelings of sadness, hopelessness) and Schizoaffective disorder, Bipolar Type (hallucinations, delusions, disorganized thinking). Record review of a Quarterly MDS assessment dated [DATE] for Resident #6 indicated a BIMS score of 3, indicating a severe cognitive impairment. He exhibited no behavioral symptoms directed toward others. He required substantial/maximal assistance with most ADLs. Record review of a comprehensive care plan dated 10/3/25 indicated he initiated aggressive behavior to another resident (pushing) on 10/3/25. Record review of an incident report dated 10/3/25 for Resident #6 indicated he pushed another resident causing the other resident to fall. Record review of a nursing progress note dated 10/3/25 at 7:30 am for Resident #6 indicated he was observed pushing another patient while in the dining room. Progress note was signed by LVN C. During an interview on 10/20/25 at 10:20 am Resident # 6 did not recall any incidents where he pushed another resident. During an interview on 10/20/2025 at 9:40 AM, the Administrator Said she had 24 hours to report abuse to the state agency. She asked after further questioning am I supposed to report abuse within 2 hours? She said she did not have an excuse why she did not report the resident-to-resident altercations within the 2-hour required reporting time frame. She said she did not report the incident with Resident #1 and Resident #2 to the state because neither resident was hurt and she just didn't report it. She said she did not know Resident #1 had a non-displaced fracture to the nose. She said she did not know that she was supposed to complete a 5-day investigation and submit it to the state agency. During an interview on 10/20/2025 at 10:38 AM, CNA K said on 10/08/2025 she was working on the secure unit. She said Resident #1 was in the dining room at breakfast and was moving the table. She said Resident #3 told Resident #1 to stop moving the table. She said Resident #1 continued to move the table and Resident #3 got up and went over to Resident #1 and started punching him in the face with a closed fist. She said her, the nurse and the other CNA separated Resident #1 and Resident #3, and both residents were sent out to the hospital. She said both residents returned from the hospital and both residents were sent out to the behavioral hospital the same day. During an interview on 10/20/25 at 11:00 AM, the Administrator said she did not know what the 3613A was. She said she had not completed them nor sent in any 5-day investigations to the state agency's reporting website. When asked what the reporting time frame was for abuse, she stated 24 hours. When surveyor further questioned administrator, she asked if it was 2 hours. The Administrator said she did not know she was supposed to complete an investigation and did not know what an investigation consisted of. During an interview on 10/21/2025 at 3:35 PM, CNA L said Resident #1 and Resident #2 were at the dining room table eating and Resident #1 kept moving the table. She said Resident #2 got up and started punching Resident #1 in the face. She said LVN C stepped in and stopped the altercation. During an interview on 10/21/2025 at 3:44 PM, LVN C said on 10/08/2025 she was passing medications in the secure unit. She said Resident #1 and Resident #2 were sitting at the dining room table and Resident #1 was pushing the table. She said Resident #2 asked Resident #1 to stop moving the table and Resident #1 did not stop. She said Resident #2 started punching Resident #1 in the face. She said her and the CNA's separated Resident #1 and Resident #2, and Resident #1 had blood dripping down his face. She said she notified the DON and the Administrator and sent both residents out to the hospital. She said Resident #1 had a non-displaced nose fracture. She said she completed an incident report and began reaching out to the behavioral hospital to have residents placed. She said both residents returned from the hospital and then both residents were sent to the behavioral hospital on the same day. During an interview on 10/22/2025 at 10:45 AM, the ADON said she found out about the resident-to-resident altercation between Resident #1 and Resident #2 in the morning meeting the day after the incident occurred. She said the residents were separated and sent to the behavioral hospital. She said she knew the Administrator was supposed to report abuse to the state agency within 2 hours. During an interview on 10/22/2025 at 3:23 PM the DON said the staff usually notified her of resident-to-resident altercations. She said she would ask staff if they had notified the Administrator and if they had not then she would notify the Administrator. She said she immediately notified the Administrator of the altercation with Resident #1 and Resident #2. She said the state agency should be notified within 2 hours of an abuse allegation. Record review of the facility's policy titled Resident to Resident Abuse, dated May 2017, indicated: .3. Begin taking written statements from the person reporting the allegation or suspicion and any witnesses including staff, family, and/or residents. In certain situations, the person writing the information, along with the person making the statement, if at all possible, and a witness to the dictated statement should sign the completed form. 4. Ask any witness to wait for the Administrator of the person on-call to arrive at the home. If an employee is involved, the employee will be detained and removed from their assigned duties until they are interviewed by the Administrator or person on-call or other appropriate staff. C.The Abuse Coordinator will: 1. Review all aspects of the investigation as soon as possible. 2. Ensure that all reports are complete and appropriate authorities have been notified, including the notification of the local law enforcement related to any crimes against a resident. 3. Complete the investigation and direct any disciplinary action required. 4. Complete the State Provider Investigation Report (5-day report). 5. Review corrective action(s). 7. Refer all occurrences to QAPI Committee to be analyzed to determine what change or changes are needed, if any, to the facilities policies and procedures to prevent further occurrences. This was determined to be an Immediate Jeopardy (IJ) on 10/21/2025 at 12:35 PM. The facility Administrator was notified. The Administrator was provided with the IJ template on 10/21/2025 at 12:35 PM. The following plan of removal submitted by the facility was accepted on 10/22/2025 at 2:54 PM: Summary of Details which lead to outcomes:On 10/20/2025 a complaint survey was initiated at [The Facility]. On 10/21/2025 a surveyor provided an IJ Template notification that it has been determined that conditions at the facility constitute an immediate jeopardy to the health and safety of the residents. The notification of the immediate jeopardy state as follows: Tag #F610 Investigate/prevent/correct alleged violation. FAILURE: The failure of keeping residents free from abuse or neglect related to failure to investigate/prevent/correct alleged violation puts residents at risk for continued injury, harm, impairment from perpetrators having continued access a risk resident. Identify residents who could be affected:All residents Problem 1: The facility failed to investigate the following incidents of alleged abuse:On 9/19/25, Resident #3 hit Resident #1.On 9/24/25, Resident #4 grabbed, pulled, and scratched Resident #5's hand.On 10/3/25, Resident #6 pushed Resident #2 to the ground.On 10/8/25, Resident #2 punched Resident #1 in the face, resulting in a non-displaced nose fracture. The facility also failed to obtain written statements, analyze the circumstances, and complete required State Provider Investigation Reports (Form 3613) for these incidents. This lack of investigation and corrective follow-up placed residents at risk of serious harm, injury, or death from further abuse. Action Taken: Residents had interventions put in place including separation from other residents when resident to resident altercations occurred. Resident #4 was separated from Resident #5, referral sent to behavioral inpatient for Resident #4, resident admitted to behavioral inpatient on 9/25/2025. Resident #6 and Resident #2 were separated from one another. Both Resident #6 & Resident #2 were sent to the ER for evaluation and treatment. Once returned both were placed on monitoring until no signs of behaviors were noted. Resident #2 & Resident #1 were separated from one another and both sent to the ER, while in the ER staff made referral to impatient behavioral hospital. Both Resident #2 & #1 were admitted to inpatient behavioral hospital. Care plans reviewed and updated as needed for incidents reported. Staff separated residents and monitored for any additional behaviors or until placement occurred for residents. When no additional behaviors occurred, residents were removed from monitoring. In house psych iatric services are contacted with behavioral incidents for evaluation and additional treatment if needed. -All staff will be re-educated on the Abuse/Neglect Policy and the procedures for reporting, documenting, and investigating all allegations of abuse or neglect- in services started on 10/20/2025 by the Administrator, the DON, nurse manager, and department managers and will continue until all staff were in serviced and no staff will work their scheduled shift until in serviced. Inservice's started by DON on 10/22/2025 to discuss resident behaviors, how to de-escalate and prevention all staff must be in-serviced before working their scheduled shift. In addition to in-services started on 10/22/2025, the facility has asked contact from local behavioral hospital to conduct training with staff during mandatory Inservice. -Inservice's started on 10/20/2025 related to reporting allegations of abuse to Administrator and DON immediately. Re-education was started on 10/20/25 and will continue no staff is to work their scheduled shift until in services are completed for them. RDO trained Administrator and DON on 10/21/2025 at 2:00 PM on investigating, prevention, and report abuse/neglect allegations. RDO in serviced Administrator/DON on 10/21/2025 with this information. Staff in services were started with staff over completing witness statements, abuse and neglect (timely reporting and types of abuse), safety surveys when state surveyors mentioned these issues. Revision of policy and procedure was loaded into staff communication system on 10/21/2025 at 2:53 PM so everyone who has already signed in services was made aware of revision to policy. -Regional Director of operations visits the facility on monthly basis and will follow up with the Administrator/DON with each self-report to ensure investigation of self-reports are completed in timely manner and 3613 is submitted to state with all the documentation gathered with investigation. All communication between monthly visits is to be sent through email. The in services for documentation including witness statements and monitoring was started on 10/20/2025 for required documentation that is needed with incidents, including witness statements and monitoring, all staff will be in services prior to start of shift. Nurse manager started Inservice on 10-21-2025 for all Documentation including incident reports, witness statements, skin assessments, treatments for injuries, interventions that were put in place to protect the residents, in services to help prevent incident from further occurring, monitoring documentation, any hospital records, safety surveys and any additional information that is required for investigation. This information was also included in facility communication for all nurses on 10-21-2025.-On 10/21/2025 department heads started safety survey rounds for residents. Charge nurse on secured unit contacting family members for residents that reside on the secured unit to complete safety survey for residents that have impaired cognition started on 10/21/2025 facility is awaiting phone calls from 4 family members where facility left voicemail. -Resident counsel scheduled with residents on 10/22/2025 to discuss changes to policy and what is required when these types of allegations are reported. Department heads will speak to each resident that did not attend resident council meeting individual and for those that have impaired cognition family members will be contacted. Monitoring -The Administrator and DON will personally review all incident reports and abuse allegations within 2 hours of occurrence to ensure timely reporting, investigation, and documentation.-The Social Services Director and Unit Managers will monitor daily for any new behavioral incidents and report immediately to administration.-The DON or Designee will complete a daily audit of all incident logs for the next 30 days, then weekly for 90 days.-Audit results will be documented and discussed in QA meeting for review and corrective follow-up. Any staff member who fails to report, investigate, or document an allegation of abuse appropriately will be subject to disciplinary action up to and including termination.The QA Committee will review all incident reports and abuse allegations monthly for 90 days to ensure that each incident is investigated, documented, and reported according to policy. Monitoring of the POR included the following: Record review of inservice titled Abuse and Neglect P&P, dated 10/21/2025, completed by the DON and Administrator. Record review of inservice titled Abuse/Neglect Policy-reporting/investigating/Implementing, dated 10/21/2025, completed by the DON and Administrator. Record review of inservice titled Resident Behaviors, De-escalation, & Prevention, dated 10/22/2025, completed by 16 employees. Record review of inservice titled Abuse & Neglect In-Service Timely Reporting, dated 10/20/2025, completed by 74 employees. Record review of inservice titled Abuse and Neglect P&P, dated 10/21/2025, completed by the DON and Administrator. Record review of inservice titled Abuse and Neglect Inservice which covered witness statements, and all incidents to be turned into the Administrator and DON, dated 10/20/2025, completed by 57 employees. Record review of inservice, dated 10/21/2025, titled Documentation requirements for incidents completed by 24 employees. Record review of 61 resident safety surveys completed 10/21/2025 documented no concerns for abuse or neglect. Record review of resident council minutes dated 10/22/2025 at 11:12 AM with 11 residents in attendance. During interviews conducted on 10/22/2025 between 3:00 PM and 4:30 PM the following staff were able to verbalize understanding of developing and implementing the facilities abuse policy: Administrator, DON, ADON, SW, CNA A, CNA B, LVN C, Housekeeper D, LVN O, MDS Coordinator, MA E, CNA N, CNA F, LVN G, CNA H, and the Activity Director. The Administrator was informed the Immediate Jeopardy was removed on 10/22/2025 at 4:30 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, the facility failed to ensure the resident had the right to be free of abuse for 1 of 6 (Resident #1) residents reviewed for abuse. The facility failed to prevent LVN A from physically abusing Resident #1 on 9/9/2025 witnessed by CNA B and CNA C. An IJ was identified on 9/12/25 The IJ template was provided to the facility on 9/12/25 at 3:34 p.m While the IJ was removed on 9/13/25 the facility remained out of compliance at a scope of Isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ due to ongoing need for in-services on abuse and neglect, abuse coordinator and notification of abuse process. This failure could place residents at risk for physical and verbal abuse, psychosocial harm, and decreased quality of life. Findings included: Record review of the face sheet dated 9/11/2025 indicated that Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including severe intellectual disability which was below average intelligence, anxiety disorder which was intense, excessive, and persistent worry and fear about everyday situations, schizoaffective disorder which was a lifelong pattern of social withdrawal and limited emotional expression, ADHD which was a chronic condition including attention difficulty, hyperactivity and impulsiveness, cerebral palsy which was a congenital disorder of movement, muscle tone or posture, and cognitive communication deficit which was a group of disorders that affect a person's ability to communicate effectively due to underlying cognitive impairments. Record review of the MDS dated [DATE] indicated that Resident #1 had a BIMS score of 03 (severe cognitive impairment). His score indicates that he had difficulty communicating some words or finishing thoughts but was able if prompted or given time and that he missed parts or intent of conversation but comprehends most conversation. Record review of the care plan dated 9/7/25 which showed that Resident#1 was last admitted to the facility on [DATE] and was receiving services at the facility. Record review of a progress note dated 9/10/2025 indicated that Resident #1 was on the floor of his bedroom fighting with his roommate and LVN A documented attempting to sooth Resident #1 by rubbing his back and his chest and his hand getting caught in the shirt of Resident #1. It indicated that LVN A instructed CNA B and CNA C to take Resident # 1 into the hallway. LVNA indicated that he assessed Resident # 1 and noted no injury. During an interview on 9/11/25 at 4:11 p.m. CNA B said that on 9/9/25 she worked with CNA C on the evening shift. She said that at around 7:30 p.m. they were assisting Resident #1 to bed and he was being combative, hitting them and not cooperating. She said that she went to get LVN A, and he said that there was nothing he could do. She said that when she went back to the room, Resident #1 was still being combative and trying to fight with his roommate. She said that she and CNA C separated the residents and placed Resident #1 back in his wheelchair. She said that around 10:30 p.m. she and CNA C attempted to put Resident #1 in bed and he stood up and was cooperative at first but then became combative again and yelling at his roommate. Resident #1 was sitting in his chair with nothing but his shirt on and was still attempting to hit CNA B and CNA C. CNA B said that she went to get assistance from LVN A. LVN A was outside of the room and Resident #1 said you want to fight, N word?. She said that LVN A came in the room and said, you got one now and grabbed Resident #1 by the shirt up by his neck and Resident #1 was making a choking noise and crying. CNA B said that when LVN A let him go, Resident #1 sat crying in his wheelchair. Record review of the voice recording provided by CNA B on 9/11/25 at 4:30 p.m. that was recorded on 9/10/25 sometime after 6:00 p.m. and included the voice of LVA A, CNA B and CNA C as identified by CNA B. A summary of the recording was that LVN A approached CNA B and CNA C letting them know that he had to complete an incident report after being accused of abusing Resident #1. LVN A asked them what occurred in the bedroom and said that he was not confirming nor denying what occurred, but he did not remember. Both CNA B and CNA C told him that he had grabbed Resident #1 by the shirt around his neck and got into Resident #1's face when Resident #1 used a racial slur toward his roommate. LVN A then excused himself to go fill out the incident report. During an interview on 9/11/25 at 3:18 p.m. Resident #1 said that LVN A had choked him and that he was scared of LVN A. Resident #1 cried and left the interview. During an interview on 9/11/25 at 3:57 p.m. LVN A said that on 9/9/2025 he worked at the facility. He went into Resident #1's bedroom when he was fighting with his roommate. LVN A said that he was trying to calm Resident #1 down by rubbing his back and trying to talk to him. LVN A said that Resident #1 was on the floor and he was assisting him back to his chair and his hand got caught in Resident #1's t-shirt and when he pulled it out his hand went up toward Resident# 1's neck. LVN A said that Resident #1 was one of his favorite residents and that he would never abuse him. He said that residents have called him the N word before and he was not one so it does not bother him. LVN A said that he did not choke Resident #1. LVN A said that there were two CNAs in the room with him when his hand got caught in Resident #1's t-shirt. LVN A confirmed that the CNA's in the room were CNA B and CNA C. During an interview on 9/12/25 at 1:18 p.m. CNA C said that she worked on the night shift on 9/9/2025 alongside CNA B. She said around 7:30 p.m. she and CNA B were having issues with Resident #1 as he was being combative and fighting with them and his roommate. CNA C said that CNA B went to ask LVN A to come and assist them with Resident #1 and his roommate who were fighting. CNA B and CNA C got the two residents separated and they moved Resident #1 out into the day room area for a while and he was able to calm down. CNA C said that at around 10:30 p.m. she and CNA B asked Resident #1 if they could change him and get him ready for bed. She said that Resident #1 agreed and they took him to his room. She said that when they got Resident #1's brief off he became combative again and said, N word, do you want to fight? to his roommate. CNA C said that at that time LVN A came into the room and said, if you want an N, now you got one and he grabbed Resident #1 by his shirt up by his neck and got into his face. CNA C said that she was shocked and did not remember what all LVN A said to Resident #1. CNA C said that it sounded like Resident #1 was making a choking noise but he may also have been crying because when LVN A released him, Resident #1 started crying. CNA C said that LVN A said, I did not hurt you, I hurt your feelings and left the room. She said that there were no further incidents that evening. During an interview on 9/11/25 at 11:55 a.m. the Administrator said she expected staff to act professional and not choke the residents or react to anything the residents might say. The Administrator said all residents had the right to be safe from abuse. Record review of facility's Abuse and Neglect Clinical Protocol policy last revised March 2018 indicated, .This policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish . Record review of facility's Abuse-Reportable Events policy last revised May 2017 indicated, .it is the policy of this home to prohibit resident abuse or neglect in any form . Record review of facility's termination document for LVN A indicated that he was terminated on 9/11/2025 for abuse. Record review of Resident # 1's assessment dated [DATE] at 11:44 a.m. that showed no injuries on his head to toe assessment related to the incident. The Administrator was notified on 9/12/25 at 3:30 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 9/12/25 at 3:34 p.m. The facility's plan of removal was accepted on 9/13/2025 at 7:46 p.m. and included: Interventions: LVN A suspended on 9/10/25 at 7:50 a.m. Resident # 1 assessed for injury on 9/10/25 at 11:44 a.m. Roommate of Resident #1 assessed. Residents on secured unit were not showing signs of distress or pain on 9/10/25. LVN A terminated on 9/12/25 at 2:00 p.m. In-service of all staff regarding abuse and neglect started. Monitoring: Staff in-serviced on abuse and neglect included types of abuse, who to report to and when to report Resident counsel held on 9/13/2025 at 10:00am was held to discuss the incident, what was considered abuse and who must be called immediately when abuse was suspected. Residents were informed that abuse coordinator signs are posted at the end of each hall and throughout facility. All residents were given a safety survey asking if they felt safe in the facility, whether they had seen anyone in the facility being abused or neglected and who they are to report abuse to if they have a concern of abuse or neglect. On 9/13/25 at 8:30 p.m. the investigator confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: During an interview with LVN F who worked the 2-10 shift on 9/13/25 at 4:38 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN D who worked the 2-10 shift on 9/13/25 at 4:40 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN E who worked the 2-10 shift on 9/13/25 at 4:54 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA J who worked the 6 p.m. to 6 a.m. shift on 9/13/25 at 4:52 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA K who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 4:54 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA L who worked the 2-10 shift on 9/13/25 at 5:00 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA B who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 5:40 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA C who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 5:52 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN G who worked the 6 p.m. to 6 a.m. shift on 9/13/25 at 6:50 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with RN H who worked the 8 a.m.-5 p.m. shift on 9/13/25 at 6:53 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with DON who worked the 8 a.m.-5 p.m. shift on 9/13/25 at 6:58 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with Resident # 2 on 9/13/25 at 6:15 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 3 on 9/13/25 at 6:20 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 4 on 9/13/25 at 6:23 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 5 on 9/13/25 at 6:27 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 6 on 9/13/25 at 6:33 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 7 on 9/13/25 at 6:37 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 8 on 9/13/25 at 6:42 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 1 on 9/13/25 at 6:46 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 9 on 9/13/25 at 7:52 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 10 on 9/13/25 at 7:55 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 11 on 9/13/25 at 7:57 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 12 on 9/13/25 at 8:00 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 13 on 9/13/25 at 8:05 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 14 on 9/13/25 at 8:08 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 15 on 9/13/25 at 8:12 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 16 on 9/13/25 at 8:15 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 17 on 9/13/25 at 8:18 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 18 on 9/13/25 at 8:20 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 19 on 9/13/25 at 8:23 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 20 on 9/13/25 at 8:25 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. Record review of safety surveys conducted on 9/13/25 indicated that they had conducted a safety survey with all residents at the facility and all who were able to participate were able to identify who to report abuse to and how to report and all indicated that they had not observed any abuse or neglect. Record review of in-service documentation dated 9/12/2025 showed that all but six staff on all shifts had been in-serviced on abuse and neglect and all staff had been notified that they would be taken off the schedule until they had been in-serviced on abuse and neglect. Record review of in-service documentation dated 9/12/2025 indicated that CNA B and CNA C were in-serviced on abuse, neglect and reporting requirements. This in-service shows that it included specific reporting requirements that abuse must be reported immediately to the abuse coordinator and that it must be reported by voice phone call, not text message. Observation conducted on 9/13/25 at 8:15 p.m. showed a notice over all facility time clocks notifying staff not to clock in until they had completed required in-services on abuse and neglect. Notification to the Administrator on 9/13/2025 at 8:30 p.m. that the IJ had been lifted. An IJ was identified on 9/12/25. The IJ template was provided to the facility on 9/12/25 at 3:34 p.m. While the IJ was removed on 9/13/25 the facility remained out of compliance at a scope of Isolated and severity level of no actual harm with potential for more than minimal harm that was not IJ due to ongoing need for in-services on abuse and neglect, abuse coordinator and notification of abuse process.

Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but 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 through established procedures for 1 of 6 (Resident #1) residents reviewed for abuse. The facility failed to ensure an allegation of abuse was immediately reported to the abuse coordinator. The facility failed to report the allegation of abuse within 2 hours. An IJ was identified on 9/12/25 The IJ template was provided to the facility on 9/12/25 at 3:34 p.m While the IJ was removed on 9/13/25 the facility remained out of compliance at a scope of Isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ due to ongoing need for in-services on abuse and neglect, abuse coordinator and notification of abuse process. This failure could place residents at risk for physical and verbal abuse, psychosocial harm, and decreased quality of life. Findings included: Record review of the face sheet dated 9/11/2025 indicated that Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including severe intellectual disability which was below average intelligence, anxiety disorder which was intense, excessive, and persistent worry and fear about everyday situations, schizoaffective disorder which was a lifelong pattern of social withdrawal and limited emotional expression, ADHD which was a chronic condition including attention difficulty, hyperactivity and impulsiveness, cerebral palsy which was a congenital disorder of movement, muscle tone or posture, and cognitive communication deficit which was a group of disorders that affect a person's ability to communicate effectively due to underlying cognitive impairments. Record review of the MDS dated [DATE] indicated that Resident #1 had a BIMS score of 03 which was indicative of severe cognitive impairment. Record review of the care plan dated 9/7/25 which shows that Resident#1 was last admitted to the facility on [DATE] and was receiving services at the facility. Record review of progress note dated 9/10/2025 indicated that Resident #1 was on the floor of his bedroom fighting with his roommate and LVN A documented attempting to sooth Resident#1 by rubbing his back and his chest and his hand getting caught in the shirt of Resident #1. It indicated that LVN A instructed CNA B and CNA C to take Resident # 1 into the hallway. LVNA indicated that he assessed Resident # 1 and noted no injury. During an interview on 9/11/25 at 4:11 p.m. CNA B said that on 9/9/25 she worked with CNA C on the evening shift. She said that at around 10:30 p.m. she observed LVN A grab Resident #1 by the shirt near his neck and that she heard Resident #1 make a choking noise and cry once released. She said that she would consider the actions she witnessed LVN A carry out to be abuse. She said she sent a text to the DON at 10:39 p.m. and 10:46 p.m. letting the DON know about the incident and that she did not know what to do. She said she did not contact anyone else and did not try to call the DON. CNA B said she did not know who the abuse coordinator was at the time of the incident and did not recall being trained on abuse and neglect. She said she got a text the next morning at 6:38 a.m. from the DON asking her to call her. She said that the risk of not reporting abuse immediately was that LVN A could have gone back and carried out more abuse or abused other residents before his shift ended. Record review of the voice recording provided by CNA B on 9/11/25 at 4:30 p.m. that was recorded on 9/10/25 sometime after 6:00 p.m. and included the voice of LVA A, CNA B, and CNA C as identified by CNA B. A summary of the recording was that CNA B and CNA C acknowledged that they observed LVN A grab Resident #1 by the shirt and around his neck on 9/9/25. Both CNA B and CNA C told him that they had observed him grab Resident #1 by the shirt around his neck and got into Resident #1's face when Resident #1 used a racial slur toward his roommate. During an interview on 9/11/25 at 3:18 p.m. Resident #1 said that LVN A had choked him and that he was scared of LVN A. Resident #1 cried and left the interview. During an interview on 9/11/25 at 3:57 p.m. LVN A said that on 9/9/2025 he worked at the facility. He went into Resident #1's bedroom when he was fighting with his roommate. LVN A said that he was trying to calm Resident #1 down by rubbing his back and trying to talk to him. LVN A said that Resident #1 was on the floor and he was assisting him back to his chair and his hand got caught in Resident #1's t-shirt and when he pulled his hand out of Resident #1's shirt and it went up toward Resident #1's neck. LVN A said that Resident #1 was one of his favorite residents and that he would never abuse him. He said that residents have called him the N word before and he was not one so it does not bother him. LVN A said that he did not choke Resident #1. LVN A said that there were two CNAs in the room with him when his hand got caught in Resident #1's t-shirt. LVN A confirmed that the CNA's in the room were CNA B and CNA C. During an interview on 9/12/25 at 1:18 p.m. CNA C said that she worked on the night shift on 9/9/2025 alongside CNA B. She said around 10:30 p.m. she witnessed LVN A enter the bedroom and grab Resident #1 by the shirt causing him to make a choking noise and cry when he was released. She said that what she witnessed was abuse and she had 24 hours to report it and intended to after the shift was over, but never got the chance to report it because she was contacted by the DON at around 7:00 a.m. the next morning. She said the Administrator was the abuse coordinator. She said that the risk of not reporting abuse immediately was that further abuse can occur. During and interview with the DON on 9/12/2025 at 9:11 a.m. DON said that she was notified by text of the abuse at 10:45 p.m. on 9/9/2025 but did not see the text until the following morning and immediately asked CNA B to call her. She said that once she spoke to CNA B and CNA C she reported the incident to the abuse coordinator who was the administrator and started the investigation process. During an interview on 9/11/25 at 11:55 a.m. the Administrator said she expected staff to report abuse within two hours so that appropriate protections can be put in place to protect the residents. The Administrator said she reported the incident of alleged abuse on 9/10/25 as soon as she found out about the incident on 9/9/25. The Administrator said she expected staff to immediately report any incidents of alleged or suspected abuse to her immediately. The Administrator said the importance of reporting abuse to the state agency in a timely manner was to aid in preventing further abuse and to protect the residents from abuse. Record review in TULIP on 9/11/25 indicated that the incident of abuse occurred on 9/9/25 at 10:45 p.m. and was reported to the State on 9/10/25 at 8:30 a.m. TULIP is a web based online platform developed and maintained by the Texas Health and Human Services Commission. It served as a centralized electronic system for handling licensure, credentialing, renewals, and related regulatory processes for long-term care providers in Texas, with a particular focus on nursing facilities. Record review of a screenshot obtained on 9/11/25 at 4:25 p.m. showed a text message from CNA B to DON at 10:39 p.m. asking if DON was awake. Another message sent at 10:44 p.m. indicated that CNA B did not know what to do in a situation that she described by saying that Resident #1 had been combative and that LVN A had put his hands around Resident #1's neck causing him to make a choking noise. LVN A was raising his voice and Resident #1 was crying. A return text from DON at 6:38 a.m. asked CNA B to call her. Record review of facility's Abuse and Neglect Clinical Protocol policy last revised March 2018 indicated, .This policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish . Record review of facility's Abuse-Reportable Events policy last revised May 2017 indicated, .it was the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law and any incident/event in which there was cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person.Nursing facility must report the above immediately but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury . The Administrator was notified on 9/12/25 at 3:30 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 9/12/25 at 3:34 p.m. The facility's plan of removal was accepted on 9/13/2025 at 7:46 p.m. and included: Interventions: LVN A suspended on 9/10/25 at 7:50 a.m. Resident # 1 assessed for injury on 9/10/25 at 11:44 a.m. Roommate of Resident #1 assessed. Residents on secured unit were not showing signs of distress or pain on 9/10/25. LVN A terminated on 9/12/25 at 2:00 p.m. In-service of all staff regarding abuse and neglect to include reporting abuse immediately to the administrator who was the abuse coordinator. Administrator completed one on one in-service with both witness CNA B on 9/12/2025 at 10:00pm. Witness CNA C was in serviced on 9/13/2025 at 1:30pm. Resident counsel held on 9/13/2025 at 10:00am was held to discuss the incident, what was considered abuse and who must be called immediately when abuse was suspected. Residents were informed that abuse coordinator signs are posted at the end of each hall and throughout facility. Monitoring: Staff in-serviced on abuse and neglect included types of abuse, reporting timely, who to report to and when to report In-service on facility abuse coordinator and back up coordinator and that a phone call must be made, text was not acceptable when it was regarding abuse. All residents were given a safety survey asking if they felt safe in the facility, whether they had seen anyone in the facility being abused or neglected and who they are to report abuse to if they have a concern of abuse or neglect. Abuse coordinator signs are throughout the facility and there will continue to be ongoing training to ensure the staff was knowledgeable of who to report to and what to report. Staff was in serviced by Administrator, DON, Dietary supervisor, and housekeeping supervisor. All staff in facility must be in serviced. As of 9/13/2025 at 11:54am 66 employees in all departments have signed in services. Twelve employees that need to be still in-services, all employees must be in-serviced by 9/13/2025 by 3:30pm any staff that has not been in-serviced was not to clock into the facility until they have been in serviced by DON or administrator anyone who fails to complete in-service will be removed from schedule and not allowed to work until they have been in serviced. On 9/13/25 at 8:30 p.m. the investigator confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: During an interview with LVN F who worked the 2-10 shift on 9/13/25 at 4:38 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN D who worked the 2-10 shift on 9/13/25 at 4:40 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN E who worked the 2-10 shift on 9/13/25 at 4:54 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA J who worked the 6 p.m. to 6 a.m. shift on 9/13/25 at 4:52 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA K who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 4:54 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA L who worked the 2-10 shift on 9/13/25 at 5:00 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA B who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 5:40 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA C who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 5:52 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN G who worked the 6 p.m. to 6 a.m. shift on 9/13/25 at 6:50 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with RN H who worked the 8 a.m.-5 p.m. shift on 9/13/25 at 6:53 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with DON who worked the 8 a.m.-5 p.m. shift on 9/13/25 at 6:58 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with Resident # 2 on 9/13/25 at 6:15 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 3 on 9/13/25 at 6:20 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 4 on 9/13/25 at 6:23 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 5 on 9/13/25 at 6:27 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 6 on 9/13/25 at 6:33 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 7 on 9/13/25 at 6:37 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 8 on 9/13/25 at 6:42 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 1 on 9/13/25 at 6:46 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 9 on 9/13/25 at 7:52 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 10 on 9/13/25 at 7:55 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 11 on 9/13/25 at 7:57 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 12 on 9/13/25 at 8:00 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 13 on 9/13/25 at 8:05 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 14 on 9/13/25 at 8:08 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 15 on 9/13/25 at 8:12 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 16 on 9/13/25 at 8:15 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 17 on 9/13/25 at 8:18 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 18 on 9/13/25 at 8:20 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 19 on 9/13/25 at 8:23 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 20 on 9/13/25 at 8:25 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. Record review of facility's in-service documentation reviewed on 9/11/25 for Reporting Abuse and Neglect dated 9/10/2025 indicated that 13 employees had been in-serviced. CNA B and CNA C were not listed on this document. Record review of safety surveys conducted on 9/13/25 indicated that they had conducted a safety survey with all residents at the facility and all who were able to participate were able to identify who to report abuse to and how to report and all indicated that they had not observed any abuse or neglect. Record review on 9/13/25 at 8:10 p.m. of in-service documentation showed that all but six staff had been in-serviced on abuse and neglect and all staff had been notified that they would be taken off the schedule until they had been in-serviced on abuse and neglect and reporting requirements. Record review of in-service documentation dated 9/12/2025 indicated that CNA B and CNA C were in-serviced on abuse, neglect and reporting requirements. This in-service shows that it included specific reporting requirements that abuse must be reported immediately to the abuse coordinator and that it must be reported by voice phone call, not text message. Observation conducted on 9/13/25 at 8:15 p.m. showed a notice over all facility time clocks notifying staff not to clock in until they had completed required in-services on abuse and neglect. Observation conducted on 9/13/25 at 8:00 p.m. of abuse coordinator signs located on each hallway, at each nurses station and in the dining room. It included the name of the Administrator as well as the number to the abuse hotline. Record review of Resident #1's skin assessment dated [DATE] at 11:44 a.m. showed no signs of injury. Notification to Administrator on 9/13/2025 at 8:30 p.m. that the IJ had been lifted. An IJ was identified on 9/12/25. The IJ template was provided to the facility on 9/12/25 at 3:34 p.m. While the IJ was removed on 9/13/25 the facility remained out of compliance at a scope of Isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ due to ongoing need for in-services on abuse and neglect, abuse coordinator and notification of abuse process.

Based on observation, interview and record review the facility failed to in response to allegations of abuse, neglect, exploitation, or mistreatment, prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress for 1 of 6 (Resident #1) residents reviewed for abuse. LVN A physically abused Resident #1 on 9/9/25 and the facility failed to protect residents from further potential abuse when LVN A returned to the facility on the night shift of 9/10/2025 after being suspended at 7:50 a.m. on 9/10/25. An IJ was identified on 9/12/25. The IJ template was provided to the facility on 9/12/25 at 3:34 pm. While the IJ was removed on 9/13/25 the facility remained out of compliance at a scope of Isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ due to ongoing need for in-services on abuse and neglect, abuse coordinator and notification of abuse process. This failure could place residents at risk for physical and verbal abuse, psychosocial harm, and decreased quality of life.Findings included: Record review of the face sheet dated 9/11/2025 indicated that Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including severe intellectual disability which was below average intelligence, anxiety disorder which was intense, excessive, and persistent worry and fear about everyday situations, schizoaffective disorder which was a lifelong pattern of social withdrawal and limited emotional expression, ADHD which was a chronic condition including attention difficulty, hyperactivity and impulsiveness, cerebral palsy which was a congenital disorder of movement, muscle tone or posture, and cognitive communication deficit which was a group of disorders that affect a person's ability to communicate effectively due to underlying cognitive impairments. Record review of the MDS dated [DATE] indicated that Resident #1 had a BIMS score of 03 which was indicative of severe cognitive impairment. Record review of the care plan dated 9/7/25 which showed that Resident#1 was last admitted to the facility on [DATE] and was receiving services at the facility. During an interview on 9/11/25 at 4:11 p.m. CNA B said that on 9/10/25 she worked with CNA C on the evening shift. She said that they were outside smoking around 9:40 p.m. when LVN A approached them and asked them about the incident the night before between LVN A and Resident #1 and that he did not remember but was at the facility to document an incident report about it. She said that she did not know that LVN A was under investigation and that if she had she would have reported it. She said that the risk of not knowing that he was under investigation was that he could have come to the facility for retaliation which placed the staff and residents at risk of abuse. She said that LVN A got onto the computer and went onto the secured unit but she did not see him interact with any residents. CNA A said that the incident the night before that she was referring to was LVN A grabbing Resident # 1 by the shirt and making him choke. Record review of the voice recording provided by CNA B on 9/11/25 at 4:30 p.m. that was recorded on 9/10/25 sometime after 6:00 p.m. and included the voice of LVA A, CNA B, and CNA C as identified by CNA B. A summary of the recording was that CNA B and CNA C acknowledged that they observed LVN A grab Resident #1 by the shirt and around his neck on 9/9/25. LVN A admitted that he had returned to the facility to document the incident from last night with Resident #1. LVN A said that he got allegations for beating up on [unintelligible]. During an interview on 9/11/25 at 3:18 p.m. Resident #1 said that LVN A had choked him and that he was scared of LVN A. Resident #1 cried and left the interview. During an interview on 9/11/25 at 3:57 p.m. LVN A said that on 9/9/2025 he worked at the facility. He went into Resident #1's bedroom when he was fighting with his roommate. LVN A said that he was trying to calm Resident #1 down by rubbing his back and trying to talk to him. LVN A said that Resident #1 was on the floor and he was assisting him back to his chair and his hand got caught in Resident #1's t-shirt and when he pulled his hand out of Resident #1's shirt and his hand went up toward Resident #1's neck . LVN A said that Resident #1 was one of his favorite residents and that he would never abuse him. He said that residents have called him the N word before and he was not one so it does not bother him. LVN A said that he did not choke Resident #1. LVN A said that there were two CNAs in the room with him when his hand got caught in Resident #1's t-shirt. LVN A confirmed that the CNA's in the room were CNA B and CNA C. LVN A said that he was informed by DON that he was suspended pending an investigation on the morning of 9/10/25 and was told that he could likely return to work on Saturday if everything looked good. During an interview on 9/12/25 at 1:18 p.m. CNA C said that she worked on the night shift on 9/10/2025 alongside CNA B. She said around 9:30 p.m. LVN A came up to her and CNA B and started talking to them about the incident that had occurred the night before with LVN A grabbing Resident #1 by the shirt and throat and making him make a choking sound. She said that he told them that he comes back to work on Saturday 9/13/25, but he had come up to the facility on the night of 9/10/25 to document an incident report about the night before. She said that she did not know he was suspended and if she had she would have reported it and not allowed him to have access to the residents. She said that she saw LVN A get on the computer but did not see him go onto the secured unit or interact with any residents. She said the risk of not knowing who was suspended was that the suspended person could come to the facility to do harm to staff or residents. Record review of facility Incident Audit Report indicated that LVN A entered an incident audit report into PCC on 9/10/25 at 10:53 p.m. PCC was the electronic medical record used by the facility. The note indicated that LVN A entered the bedroom of Resident #1 and Resident #1 was on the floor trying to fight with his roommate. LVN A documented that he directed the CNA to put Resident #1 in his wheelchair and get him out of the room. LVN A documented that Resident #1 was agitated and that LVN A was rubbing his back to calm him down and then was rubbing his chest as a calming procedure. LVN A documented that his hand slipped inside the shirt of Resident #1 as he was bending down to fight with his roommate and LVN A stated that he removed his hand immediately and asked the CNAs to removed Resident #1 from the room. LVN A noted that Resident #1 was assessed for injury and none were found. During an interview on 9/11/25 at 11:55 a.m. the Administrator said she expected suspended staff to not enter the facility during their suspension and there was a policy entitled Disciplinary Action and Suspension Pending Investigation Policy that told them. She said that they did not tell other staff when a staff member was suspended as they did not want to spread their business and that she was not aware of any policy that directed the Administrator or DON to notify anyone of a suspended staff member. She said she assumed that a suspended staff member's common sense would tell them that they should not be at the facility during suspension in addition to that policy. She said that she understands the need for a process for others to know about the suspension as a suspended person coming to the facility places everyone at the facility at risk of abuse or assault. She said that she was not aware that LVN A was at the facility after he was notified on 9/10/25 at 7:50 a.m. that he was suspended. She said that they started the investigation upon being notified of the incident by interviewing CNA B and CNA C, assessing Resident # 1 and in-servicing staff on abuse and neglect. Record review of facility's Disciplinary Action and Suspension Pending Investigation Policy undated indicated, .In cases involving serious allegations, employees may be placed on suspension pending investigation and are not permitted to return to the facility until the investigation was concluded.the employee was not permitted on facility premises or to engage with residents or staff during the suspension . Record review of the document titled {Facility} New Hire/Status Change Form which indicated that LVN A was terminated on 9/11/25 for abuse. This document did not show a suspension date or time. Record review of facility's Employee Discipline Policies and Professional and Personal Responsibility policy indicated that the suspended employee was not to enter premises until suspension was complete or until results are determined from suspension. Record review of facility's Abuse-Reportable Events policy last revised May 2017 indicated, .it is the policy of this home to prohibit resident abuse or neglect in any form . The Administrator was notified on 9/12/25 at 3:30 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 9/12/25 at 3:34 p.m. The facility's plan of removal was accepted on 9/13/2025 at 7:46 p.m. and included: Interventions: LVN A suspended on 9/10/25 at 7:50 a.m. Resident # 1 assessed for injury on 9/10/25 at 11:44 a.m. Roommate of Resident #1 assessed on 9/10/25. Residents on secured unit were not showing signs of distress or pain on 9/10/25. LVN A terminated on 9/12/25 at 2:00 p.m. In-services related to abuse/neglect started 9/10/2025 at 8:00am. Updated policy on suspension pending investigation with Be informed when an employee is suspended-suspended employee is not allowed to be in facility and all staff must ask the suspended staff to leave and call the administrator/DON if they enter the facility. Monitoring: Policy on suspension pending investigation updated. All staff will be informed each time an employee was suspended and will be responsible for asking staff to leave if they come to the premises and contact Administrator and DON. Any employee suspected of abuse will be removed from the facility immediately. Abuse coordinator signs are throughout the facility and there will continue to be ongoing training to ensure the staff was knowledgeable of who to report to and what to report. Staff was in serviced by Administrator, DON, Dietary supervisor, and housekeeping supervisor. All staff in facility must be in serviced. As of 9/13/2025 at 11:54am 66 employees in all departments have signed in services. There are twelve employees that need to be still in-services. All employees must be in-serviced by 9/13/2025 by 3:30pm. Any staff that has not been in-serviced was not to clock into the facility until they have been in serviced by DON or administrator. Anyone who fails to complete in-service will be removed from schedule and not allowed to work until they have been in-serviced. On 9/13/25 at 8:30 p.m. the investigator confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: During an interview with LVN F who worked the 2-10 shift on 9/13/25 at 4:38 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN D who worked the 2-10 shift on 9/13/25 at 4:40 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN E who worked the 2-10 shift on 9/13/25 at 4:54 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA J who worked the 6 p.m. to 6 a.m. shift on 9/13/25 at 4:52 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA K who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 4:54 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA L who worked the 2-10 shift on 9/13/25 at 5:00 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA B who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 5:40 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA C who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 5:52 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN G who worked the 6 p.m. to 6 a.m. shift on 9/13/25 at 6:50 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with RN H who worked the 8 a.m.-5 p.m. shift on 9/13/25 at 6:53 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with DON who worked the 8 a.m.-5 p.m. shift on 9/13/25 at 6:58 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with Resident # 2 on 9/13/25 at 6:15 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 3 on 9/13/25 at 6:20 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 4 on 9/13/25 at 6:23 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 5 on 9/13/25 at 6:27 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 6 on 9/13/25 at 6:33 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 7 on 9/13/25 at 6:37 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 8 on 9/13/25 at 6:42 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 1 on 9/13/25 at 6:46 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 9 on 9/13/25 at 7:52 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 10 on 9/13/25 at 7:55 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 11 on 9/13/25 at 7:57 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 12 on 9/13/25 at 8:00 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 13 on 9/13/25 at 8:05 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 14 on 9/13/25 at 8:08 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 15 on 9/13/25 at 8:12 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 16 on 9/13/25 at 8:15 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 17 on 9/13/25 at 8:18 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 18 on 9/13/25 at 8:20 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 19 on 9/13/25 at 8:23 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 20 on 9/13/25 at 8:25 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. Record review of facility's in-service documentation reviewed on 9/11/25 for Reporting Abuse and Neglect dated 9/10/2025 indicated that 13 employees had been in-serviced. CNA B and CNA C were not listed on this document. Record review on 9/13/25 at 8:10 p.m. of in-service documentation showed that all but six staff had been in-serviced on the changes to the suspension pending investigation policy and all staff had been notified that they would be taken off the schedule until they had been in-serviced. Record review of in-service documentation dated 9/12/2025 indicated that CNA B and CNA C were in-serviced on abuse, neglect and reporting requirements. This in-service shows that it included specific reporting requirements that abuse must be reported immediately to the abuse coordinator and that it must be reported by voice phone call, not text message. Record review on 9/13/25 at 8:12 p.m. of the facility suspension pending investigation policy update. There was no date on the policy but the change from the old policy to the new policy was the addition that was as follows: All staff must be informed when an employee is suspended- Suspended employee is not to be in the facility and staff must ask them to leave and call the administrator/DON if they enter the facility. Observation conducted on 9/13/25 at 8:00 p.m. of abuse coordinator signs located on each hallway, at each nurses station and in the dining room. It included the name of the Administrator as well as the number to the abuse hotline. Observation conducted on 9/13/25 at 8:15 p.m. showed a notice over all facility time clocks notifying staff not to clock in until they had completed the required in-services on recent policy changes. Record review of Resident #1's skin assessment dated [DATE] at 11:44 a.m. showed no signs of injury. Notification to Administrator on 9/13/2025 at 8:30 p.m. that the IJ had been lifted. An IJ was identified on 9/12/25 The IJ template was provided to the facility on 9/12/25 at 3:34 p.m. While the IJ was removed on 9/13/25 the facility remained out of compliance at a scope of Isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ due to ongoing need for in-services on abuse and neglect, abuse coordinator and notification of abuse process.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 2 of 3 residents (Resident #1 and Resident #4) reviewed for accidents. The facility failed to keep Resident #1 in a safe environment to prevent an elopement on 4/26/2024 when he climbed out of a window in the secured unit. The facility failed to keep Resident #2 in a safe environment to prevent an elopement on 8/23/2024 when he walked out an unlocked door in the secured unit. An Immediate Jeopardy (IJ) situation was identified on 12/10/2024 at 1:32 PM. While the IJ was removed on 12/12/2024 at 1:27 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective systems. These failures could place residents at risk for serious injury and accidents. Findings included: 1. Record review of an Admission Record dated 5/08/2024 for Resident #1 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Major Depressive Disorder and mild cognitive impairment. Record review of an admission Elopement/Wandering Evaluation dated 4/10/2024 for Resident #1 indicated he admitted to the facility on [DATE]. He had diagnoses of dementia/cognitive impairment, ambulated without assistance, could communicate, and had a history of wandering in the last month. He was indicated as a high risk for elopement with a score of 11. Score ranges: low risk 0-8, at risk 9-10 and high risk 11 or above . Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated he had moderate impairment in thinking with a BIMS score of 8. Resident had history of rejecting care, and dangerous wandering that intruded on the privacy and activities of others. Record review of an Elopement/Wandering Evaluation dated 4/19/2024 for Resident #1 indicated he admitted to the facility on [DATE]. He had diagnoses of dementia/cognitive impairment, ambulated without assistance, could communicate, and had a history of wandering in the last month. He was indicated as a high risk for elopement with a score of 12. Score ranges: low risk 0-8, at risk 9-10 and high risk 11 or above . Record review of a care plan dated 4/25/2024 for Resident #1 indicated he had secure unit placement and was an elopement risk/wanderer related to dementia. History of wandering, elopement attempts, previous elopement on 4/19/24. Interventions included identify and document wandering behavior and attempted diversional interventions. Record review of a witness statement dated 5/03/2024 by LVN F indicated she observed Resident #1 sitting on the couch in the TV room talking to CNA H approximately 10 minutes before the incident. LVN F reported Resident #1 had not exhibited any elopement attempts this shift. LVN F reported when Resident #1 was returned to the unit he was alert and oriented to person and place and told her he pulled a nail out of the wall and used it to open the window and crawled out to go to the store and buy smokeless tobacco. LVN F reported there were no injuries and resident was placed on 1-1 staff observation for safety . Record review of a witness statement dated 5/03/2024 by CNA H indicated he was sitting on the sofa talking to Resident #1 when Resident #1 said he wanted to go to the store to buy Skoal and diet Mt. Dew. CNA H reported he told Resident #1 the store was closed right now, but someone would get it for him when it opened. CNA H reported Resident #1 went into his room and closed the door, which was Resident #1's usual behavior. Record review of a witness statement in provider investigation report dated 5/03/2024 by CNA G indicated she was returning from break and observed Resident #1 walking through the parking lot of the facility. CNA G asked Resident #1 if he was okay and he said he was trying to go to the store for snuff. CNA G redirected Resident #1 back into the facility and reported the incident to the charge nurse. Record review of a Q 15-minute observation form for Resident #1 indicated Q 15-minute monitoring started at the facility on 4/26/24 at 5:15 PM and ended on 4/27/2024 at 1:15 PM when resident was transferred out of the facility. Record review of an elopement/wandering evaluation post incident on 5/08/2024 indicated he had diagnoses dementia/cognitive impairment, ambulated without assistance, could communicate, and had a history of wandering in the last month, and had eloped twice in one week. He was indicated as a high risk for elopement with a score of 18. Score ranges: low risk 0-8, at risk 9-10 and high risk 11 or above. 2. Record review of a facility face sheet dated 8/22/24 for Resident #2 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Major Depressive Disorder. Record review of a Quarterly MDS assessment dated [DATE] for Resident #2 indicated he had a BIMS score of 12, which indicated he had moderate cognitive impairment. He had no wandering behaviors during assessment period, had delusions (misconceptions or beliefs that are firmly held, contrary to reality), ambulated without assistance, and was dependent with most ADLs. Record review of a comprehensive care plan dated 9/27/24 for Resident #2 indicated he was an elopement risk/wanderer related to history of attempts to leave facility unattended and he wandered aimlessly. Focus included secure unit placement on 8/29/2024. Record review of a facility form titled Elopement/Wandering Evaluation dated 8/22/24 for Resident #2 indicated he was an elopement risk/wanderer related to history of attempts to leave facility unattended, he wandered aimlessly, and has medical diagnose of dementia/cognitive impairment. Record review of Provider Investigation Report dated 8/30/2024 indicated Resident #2 opened secure unit door and walked outside when door failed to lock. During an observation and interview on 12/09/24 at 9:05 a.m., Resident #2 was observed lying in his bed in his room on secured unit. He said he told the nurse he was going to the red light and then walked out of the secured unit doors. Resident #2 said he wanted to go to a local city . He said facility staff found him at a building next door (approximately 300ft away and next to a busy road) and gave him a ride back to the facility. During an interview on 12/9/24 at 9:10 AM with CNA K, she said she works day shift and usually works on the secured unit. She said she thinks the Maintenance Man checks door locks and alarms, but she does not know how often. She said she checks all doors on secured unit when she was rounding. During an interview on 12/9/24 at 9:15 AM with LVN A, she said she works day shift on hall 900, which was the secured unit. She said she has not had an elopement on her shift. She said Resident #1 was transferred to another facility and Resident #2 will pack up his belongings and ask to leave, but he was easy to redirect. She said all staff were expected to verify door locks and alarms were functioning each shift. She said there was no documentation to record security checks. She said the Maintenance Man also was responsible for checking door locks and alarms, but she does not know the schedule. Attempted telephone interviews with LVN D, LVN F, CNA H, left voice mail messages requesting return call. During a telephone interview on 12/9/24 at 12:10 PM, CNA G said the night Resident #1 eloped, she was coming back from break and saw Resident #1 walking through the facility parking lot. She said he told her he was going to buy snuff and asked her for a ride. She said he got into her car, and she drove him back to the facility entrance where she could see staff members outside. An observation on 12/09/2024 at 1:00 PM of the sunroom, which leads to the secured unit smoking exit door, revealed 1 of 5 windows checked did not have safety locks and opened fully. The volume of the alarm on the exit door was low, alarm was activated and monitored for approximately 10 minutes with no staff response. The exit door in sunroom exited into a fenced smoking area, which had a wooden gate that was unlocked and standing open. During an interview on 12/9/24 at 1:48 PM, the Maintenance Man said he checked all doors, windows, and alarms weekly. He said he had not been told of any problems with the doors or alarms on secured unit. He said staff turned off the alarm on the exit door to the secured smoking area, and he had to reset it with the key. He said he had trained all staff on proper securement of doors and alarms, and he had installed safety locks to keep the windows on secured unit from opening fully to prevent any resident from climbing out. He said he does not keep any maintenance logs. During an interview on 12/9/24 at 2:00 PM, CNA E said she works day shift and usually works on the secured unit. She said all staff were responsible for checking doors and alarms. She said alarms were loud enough for staff can hear them on the unit. During a telephone interview on 12/9/24 at 2:30 PM, LVN F said she was not working the night Resident #1 eloped, but it was reported to her he was able to disable the safety lock on his bedroom window and climb out. She said following the incident he was placed on 1 to 1 observation and staff tried to keep his room door open as much as he would allow them. She said the Maintenance Man installed safety locks on all windows on the secured unit following the incident. She said all staff were responsible for checking doors and alarms to make sure the unit is secured. She said risks for a resident who eloped were injuries or getting lost. An observation on 12/10/2024 at 8:35 AM of secured unit smoking area revealed the wooden gate was unlocked and standing open. An observation on 12/10/2024 at 8:50 AM of secured unit revealed a window in the dining room did not have a safety lock and opened fully. During an interview on 12/10/24 at 9:30 AM, LVN B said she works day shift and always works the secured unit. She said the unit was staffed with one dedicated nurse and two dedicated CNAs. She said nurses were responsible for checking door locks and alarms at the start of every shift and then every few hours during shift. She said CNAs on unit also assist with checking doors and alarms. She said maintenance man was responsible for ensuing all secured unit door locks and alarms were functioning properly, but she does not know how often he checks them. She said she has told the maintenance man the wooden gate in the secured smoking area does not stay locked and he told her the wind was probably blowing it open. During an interview on 12/10/24 at 12:15 AM, the DON said it was the Maintenance Man's responsibility to ensure all locks and alarms are in working order by performing weekly maintenance. She said she doesn't know if he keeps any records of work performed. She said nurses working on the secured unit were also responsible for checking door locks and alarms every shift. She said no one should be using the wooden gate in the secured smoking area except for Maintenance Man, but other staff probably uses it as well. She said it was the expectation of staff to immediately notify DON and Administrator if a resident was missing. She said staff should search the unit, perform a headcount of residents, and expand the search outside if resident isn't found. She said risks for a resident who elope from the facility were hyperthermia, heat exhaustion, or injuries. Attempted telephone interviews with LVN D and Administrator, left voice mail messages requesting return call. During a telephone interview on 12/10/24 at 4:00PM, CNA H said he was working the night of both elopements involving Resident #1 and Resident #2. He said on the evening Resident #1 eloped he had been sitting in the dining room watching TV. He said Resident #1 asked staff to get him a mountain dew and some skoal. He said LVN D explained they wouldn't be able to get him a mountain dew or skoal tonight. He said Resident #1 became agitated and went to his room and shut the door. He said he was not sure what time Resident #1 eloped, but he was seen in the parking a few minutes later by another staff member returning from break and escorted back inside facility. He said on the evening Resident #2 eloped he was rounding on residents and Resident #2 was not in his room. He said he notified LVN D, and searched hall 900 and adjoining hall 800, but Resident #2 was not located. He said about 20 minutes later resident was located outside of the facility and escorted back to the secured unit . Record review of Policy and Procedure, Subject Elopement, dated 5/2027 indicated Administration / Supervisory staff would .Determine what measures can be taken to prevent it from happening again. This was determined to be an Immediate Jeopardy (IJ) on 12/10/2024 at 1:32 PM. The facility's Administrator and DON were notified. The DON was provided the IJ template on 12/10/2024 at 1:32 PM. The following Plan of Removal (POR) submitted by the facility was accepted on 12/11/2024 at 1:15 PM. [facility] Plan of Removal 12/10/2024 Elopement Immediate actions: 1. Review of facility records by the DON identified 16 residents on the unit at risk. 12/10/2024 at 2:45pm. 2. Unit staff moved onto floor and out of nurses station to provide safety and hall monitoring while correcting findings completed at 2:45PM 12/10/24. 3. Maintenance conducted a tour of secure unit and identified the following at 2:45 PM o Secured doors on 800,900 Halls, dining room and entrance doors into secured unit.(Contractor) contacted and assessed the issues on 12/10 at 3:07 will return 12/11 to repair. Hall monitoring by designated staff in place until repairs are made. Every shift until repairs are made and documented on safety monitoring log as of 12/11. o Replaced batteries of door alarms and checked sound/volume to ensure they are heard on the unit by the staff. o Checked and provided safety locking for any identified windows without safety locks in place. One window in the sun room was not safety locked corrected 12/10 at 3:00 PM o Secured gate and added to daily maintenance round sheet to check for security. Summit security contacted to test mag lock on secured unit gate and 900 exit doors for safety purposes. 12/10/2024 will be date of visit, arrived at 3:07pm. Weekend RN manager or manager on duty will monitor and document on weekend. Weekend managers and managers on duty inserviced 12/11/2024 at 2:00 PM in-service started for all staff regarding the following: o Elopement risk and policies on preventing elopement. o Maintaining a safe and secure facility to prevent elopement, monitoring of doors, door alarms and windows for safety. 4. Maintenance man inserviced 1:1 on safety monitoring and checking batteries in alarms, mag locks on secure areas and other protocol to prevent elopement. lnservice to be completed by 12/11/2024 at 5 PM. By DON, ADON and designated administrative / manager staff. In person and via phone for all remaining staff. All of the findings will be added to QA meeting for further review and recommendations. On 12/12/2024, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Monitoring: During an observation on 12/11/24 at 2:40 PM of hall 800, 900, and secured smoking area exit revealed doors, windows, and wooden gate locked. All alarms were audible, and a staff member was posted at secured smoking area exit with. Staff member was signing a check log every 15 minutes. All other CNAs were on the floor interacting with and monitoring residents. In interviews from 12/11/24 through 12/12/24 CNA Q, Med Aide T, RN P, LVN B, CNA S, Housekeeper Supervisor, Housekeeper U, LVN V, CNA W, CNA X, CNA Y, CNA Z, ADON, CNA R, LVN BB, Activity Director, MDS nurse, LVN AA, RN CC, LVN F. All staff were able to verbalize duties related to checking doors, windows, and alarm systems as well as duties in the event of a missing resident or elopement. All staff able to demonstrate or verbalize process to ensure alarms were armed. Attempted multiple telephone interviews for additional staff members RN DD, LVN D, LVN EE. Left messages requesting return calls on voicemails. No calls were returned. In an interview on 12/11/24 at 1:48 PM, the Maintenance Man said he had received training on checking alarms, windows, and doors for security. He said he checked, daily, all windows and doors to verify they were secured, and no window opens more than 6 inches with safety locks in place. He said he checks alarms daily to verify they were loud enough to be audible for staff. Record review of an in-service training report dated 12/10/24 indicated the Maintenance Man had a 1:1 training on his roll related to all alarms, windows, and doors to be checked daily, documented, and who to report findings to. Record review of an in-service training report dated 12/11/24 training was provided to managers on duty/RN to check secured unit doors, alarms, and gates on Saturdays and Sundays in the secured unit. There were 7 staff trained, which included Activity Director, Housekeeper FF, RN P, RN GG, RN CC, RN DD, Housekeeping Supervisor. Record reviews on 12/12/24 of Elopement Risk Assessments dated 12/11/24 through 12/12/24 indicated 16 of 16 residents identified as high risk on the secured unit received an updated Elopement Risk Assessment. Record review of Secured Unit Maintenance work order dated 12/12/24 signed by Maintenance Man indicated an independent contractor repaired all door maglocks and Maintenance Man installed two window safety locks, replaced 800 hall magnet doorstop, verified all other door stops were in correct position and batteries were working, and trained all employees on both maglocks and door stop alarms. Record review of a local independent contractor invoice for work completed at the facility indicated .(local contractor performed repairs at (facility address) the door system. All doors were functioning when we left 12/11/2024. Record review of Door Stop Checklist dated 12/11/24 and 12/12/24 indicated all doorstops were checked and working properly. Record review of ALARM FUNCTION checklist for December 2024 indicated all alarms were checked, necessary repairs made, and were working properly on 12/11/24 and 12/12/24. Record reviews of the following documents: *Inservice titled Return demonstration for alarms and door magnets on secured unit dated 12/11/2024. *Inservice titled Elopement/Safety dated 12/10/2024. *Inservice titled MOD-RN managers are required to check secured unit doors, alarms and gates for proper functioning for all secured unit residents safety on Saturdays and Sundays dated 11/11/2024. *Checklist template for DOOR ALARM/FUNCTION CHECHKS (sic) *Checklist template for ALARM FUNCTION *Checklist template WINDOW CHECKS On 12/12/24 at 1:32 pm, the DON was informed the IJ was removed. However, the facility remained out of compliance at a severity no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern. The facility was continuing to monitor all secured doors, windows, and exit alarms daily, in addition to implementing documentation to record compliance.

Based on observations, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #1) reviewed for respiratory care. The facility failed to ensure LVN C did not reuse a single use suction catheter with Resident #1 on 10/31/24. The facility failed to ensure LVN C employed sterile technique during suctioning and tracheostomy care with Resident #1 on 10/31/24. The facility failed to ensure LVN C did not use tap water when performing tracheal suctioning for Resident #1 on 10/31/24. The facility failed to ensure LVN C used intermittent suctioning during care on 10/31/24. The facility failed to train nursing staff on proper tracheostomy care and tracheal suctioning procedures. An Immediate Jeopardy (IJ) was identified on 10/31/2024. While the IJ was removed on 11/2/2024 at 3:02 p.m., the facility remained out of compliance at a scope of no actual harm with potential for more than minimal harm that is not immediate jeopardy and scope of isolated due to the facility's need to monitor and evaluate the effectiveness of their corrective systems. These failures could place residents requiring tracheostomy care and tracheal suctioning at risk for respiratory complications, infections, and/or death. Findings included: Record review of a facility face sheet dated 10/26/24 for Resident #1 indicated that he was a [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses that included: quadriplegia (a symptom of paralysis that affects all limbs and body from the neck down. Record review of a comprehensive MDS assessment dated [DATE] for Resident #1 indicated that interview for BIMS score should not be conducted due to resident being rarely/never understood. Section C (cognitive patterns) indicated that he was independent with cognitive skills for daily decision making. He was dependent with all ADLs. He had a tracheostomy, an indwelling urinary catheter and an ostomy. Record review of a comprehensive care plan dated 10/3/24 for Resident #1 indicated that he had a tracheostomy and had the following interventions: .will have sterile suctioning procedure as needed . and .will have sterile tracheostomy care: cleanse around trach site and replace drain sponge. Change trach ties as needed . Record review of a physician's order summary report dated 11/2/24 for Resident #1 indicated he had the following physician's orders: .Tracheostomy care one time a day . and .may suction prn for secretions . During an interview and observation on 10/28/24 at 2:30 pm Resident #1 was observed at [hospital name] lying in his hospital bed. Resident #1 said the facility changed his ties and did trach care once a week. He said he felt like the facility was unequipped to handle his trach care. During an interview and observation on 10/31/24 at 7:50 am Resident #1 was observed in bed sitting up in bed. He said the facility did not have the staff to properly take care of him and they did not clean his trach often as they should. During an observation on 10/31/24 at 7:37 am LVN C was in Resident #1's room to provide suctioning to his trach per his request. She went into the room and washed her hands, put on a gown and nonsterile gloves in the hallway and entered the room with a plastic cup and a sterile water container. She then put on another pair of nonsterile gloves on top of the pair of gloves that were on her hands for a total of 2 gloves on each hand. She then placed the cup and sterile water on the nightstand beside the bed. She turned on the overbed light and then removed a pair of gloves and placed them in the trash. She placed another pair of nonsterile gloves on top of the gloves that were on her hands. She pulled the linens down on the resident and removed the cap that was on the trach. She removed a pair of gloves and placed them in the trash. She put on another pair of nonsterile gloves on top of the pair of gloves that were already present on her hands for a total of 2 gloves on each hand. She turned the suction machine on and removed the suction tubing from the plastic package that was already opened on one end and inserted the tubing down into the trach and suctioned. She placed the tubing in the sterile water to clean the tubing of any secretions and placed it back inside the plastic packaging that it was in previously. She placed the cap on the trach and removed her gloves and gown and placed them in the biohazard box that was in the room. She washed her hands in the bathroom and exited the room. During an observation on 10/31/24 at 9:25 am LVN C was observed performing suctioning and tracheostomy care on Resident #1. She did not use sterile technique during care. She was observed wiping down overbed table, she then washed her hands, donned gown, mask, and non-sterile gloves. She was observed to apply a second pair of non-sterile gloves over the first pair. She then opened a packet containing a sterile drape/towel and laid it on the cleaned table. She then opened trach care kit and with non-sterile gloved hands, removed each item from kit and placed it on the sterile field/drape that had been laid on an overbed table. She then opened the sterile water container and poured it into the open tray that was on sterile field with lid folded underneath it. She then opened the peroxide, also pouring it into the tray. She was observed touching all the ends of the cotton swabs and twirling them around in her fingers before placing them back down onto the sterile field. She then opened another trach kit and removed supplies from it with non-sterile gloved hand, also placing them on the sterile field and placed kit tray with lid folded underneath it on sterile field as well. She then removed top pair of gloves and discarded them. Resident #1 then requested to be suctioned. She walked away from sterile field with the supplies on it and left room. She reenters room with another sterile water container. She then removed her PPE, placed water on table next to sterile field and washed hands in restroom. She returned to hall to don more PPE, re-entered room and with non-sterile gloved hands, applied a second pair of non-sterile gloves. She then poured sterile water into a non-sterile plastic cup, turned on suction machine and removed the purple cap from resident's trach. She laid the cap on his hoodie on his chest. She then took the suction tubing in non-sterile gloved hand and removed suction catheter from previously opened bag and inserted it into resident's tracheostomy opening. After resident began to cough, she put her thumb over the opening in the tubing and suctioned the entire time she slowly withdrew (approximately 10-15 seconds, then suctioned water into the tubing. She repeated this twice. She then placed the suction catheter back into the open packaging and laid it back on table. Resident exhibited facial grimacing during the procedure. She threw away the outer gloves and applied another pair of non-sterile gloves over the first pair. She then removed the inner cannula. Inner cannula was placed in peroxide to soak. She picked up the package of sterile gloves and moved them to the edge of the sterile field. She then unvelcroed the right side of his trach collar and removed the split gauze. She then removed outer gloves and opened sterile gloves. She applied the sterile gloves over her non-sterile gloves. She then took sterile drape and placed it over his chest and just underneath his neck. She poured sterile water into the 2nd trach care plastic tray and then peroxide as well. She then placed gauze in the peroxide, squeezed out excess liquid and cleaned top of trach tube flange. She then repeated to clean the bottom. She then cleaned with cotton swabs to remove thick, yellow substance from underneath trach tube. She was observed cleaning the inside of inner cannula with pipettes and then placed it in sterile water to soak. She then removed the trach collar from the right side and attached the new collar to the right side and then walked around to the other side of resident, held outer tube in place with her left hand and unvelcroed the left side of old collar. She then pulled new collar behind his neck and velcroed in place. She then secured both sides with Velcro and placed a new split gauze. She then was observed patting dry the inner cannula with gauze pad and placed it back inside trach tube. She then removed her sterile gloves and put on a pair of non-sterile gloves over the original pair. She placed another sterile drape over his chest, turned on suction machine, took a non-sterile plastic cup into bathroom and came out with water in cup. She then suctioned him again using same technique as above with same suction catheter and then replaced suction tubing catheter back into packaging and left it lying on table. Resident again exhibited facial grimacing while suctioning. She then replaced purple trach tube cap, removed gloves and PPE, washed hands, and exited room. Date and time on suction catheter tubing observed to be 10/31/24 8:39 am. During an interview on 10/31/24 at 11:50 am LVN C said she had been employed at the facility for approximately 4 months. She said during the trach care provided to Resident #1 this morning, she was not sure what she did wrong, just maybe would have changed her gloves more. She said she did have training before employment but not a check off at the facility on trach care. She said she had never had any competency training with someone where she had to do a return demonstration and was told if the skills were correct or not. She said no skills check off were conducted. She said she thought that she had done all the correct steps. She said she was told the suction tubing was supposed to be changed out today, she thought it was changed out that morning. She said they normally use sterile water or distilled or sometimes they must use the water from the bathroom sink. She said she had not actually received any training. She said when she started, they asked her if she had trach training at another facility. She said she had 3 days of orientation, and she wasn't physically shown how to do the care but had just been told verbally how to do it. She said she was never asked if she felt comfortable with caring for him. She said sometimes she did not feel comfortable with caring for him and did not have the skills nor training to care for him. She said residents could be at risk for harm and not being properly cared for. During a telephone interview on 10/30/24 at 3:31 pm LVN D said she had been employed at the facility since August of 2024 and worked the 6am-2pm shift, rotating halls. She said she had not received any training since being in the facility. She said she had not had any training on trach care and suctioned him at least twice during her shifts and sometimes more. She said she had some trach knowledge from a previous job. During an interview on 10/31/24 at 12:20 pm the DON said trach care training with nursing staff was done on hire and yearly thereafter. She said they had an RT who would come to the facility yearly to conduct trach training with the staff. She said the last time they were at the facility was about a year ago and it was time for them to come back. She said she had trained the new employees in the facility as she had been trained by RT to train other staff on the proper procedures to care for a trach resident. She said she would train the staff unless the RT would be conducting the training. She said the training she provided to the staff was not as extensive as the RT's training. She said once the training was completed, the staff were to complete a return demonstration to show competency. She said there was a risk for improper care to the residents in the facility if the staff had not been trained on how to care for a resident who had a trach. She said trach care was a sterile technique and sterile water should be used when cleaning or suctioning. She said suction should be intermittent and not continuous when pulling the tubing out. She said trach care should be performed once a day and the floor nurses were responsible for providing trach care. During an interview on 10/31/24 at 12:46 pm Medical Director said he was the facility medical director and began his employment with the facility in September 2024. He said nursing was responsible for training the staff on proper tracheostomy care and technique. He said there was a risk for introducing organisms into the trach if the care was not done properly. He said he was not aware of any issues with tracheostomy procedures at the facility. He said he had made rounds at the facility the other day and he was aware that Resident #1 did have a trach. He said staff should follow sterile technique when providing care to a resident who had a trach. He said if care was not done properly with a trach resident, they could be at risk for pneumonia and aspiration. He said it was never acceptable for staff to use tap water when providing trach care. During a telephone interview on 10/31/24 at 4:10 pm LVN G said she had been trained on trach care by LVN C but mainly with LVN D. She said they had shown her how to suction Resident #1, clean the tubing, flush before and after fluid return, and if he asked her to go deeper when she suctioned him to tell him she could not go any farther than resistance when she inserted the tubing. She said she was told to tell him that she could not. She said she did not receive any training from RT or the DON on trach care. During an interview on 11/1/24 at 9:30 am the DON said in the last year they have had a lot of new staff, new management, and no consistent nurse manager to help her. She said LVN C was observed by her initially to do trach care and suctioning and breathing treatments, but she never received the training on trach care. The DON said she filled out the form yesterday for LVN C because she had done observation with her but did not take the test. She said the nurses should be trained yearly. She said they were done yearly. She said residents could be at risk for infections and incorrect care from not having proper training. During an interview on 11/1/24 at 9:57 am the Administrator said she was hired at the facility in August 2024. She said DON was responsible for training staff on respiratory care and said she was going to see about getting an RT to train the staff for more expertise in that area. She said residents could be at risk for trauma, infection if staff do not follow proper procedures. Record review of a competency evaluation for LVN D indicated that on 8/1/24 she was satisfactory with trach care. Record review of a competency evaluation for LVN K indicated that on 5/9/24 she was satisfactory with trach care. Record review of a competency evaluation for LVN C indicated that on 6/5/34 she was satisfactory with trach care. Record review of a competency evaluation for LVN J indicated that on 6/2/22 she was successfully trained on respiratory/trach. Record review of a facility policy titled Tracheostomy Care dated 5/2017 read .It is the policy of this home to provide Tracheostomy care in accordance with current standards of practice to ensure airway patency, maintain skin integrity, and prevent infection . and .Aseptic technique must be used/sterile gloves must be worn: during tracheostomy tube changes (non-disposable and disposable); during cleaning and sterilization of non-disposable tracheostomy tubes; .and .during endotracheal suctioning . The Administrator and DON were notified of an IJ on 10/31/24 at 2:07 pm and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 10/31/24 at 5:18 pm and included the following: 10/31/2024 Trach care Immediate actions: o Review of facility records identified 1 resident receiving Trach care. This was verified on 11/2/24 - Resident #1 o Resident #1 PCP notified, and care plan reviewed and updated as needed. o Resident #1 will be assessed and monitored q Shift for signs and/or symptoms of infection related to trach care. o One on one training and return demonstration to be conducted with LVN identified. o All nurses will show understanding by return demonstration. o One nurse from each shift will be properly trained by DON with return demonstration and be the sole nurse providing trach care on that shift by 5 pm on 10/31/2024 DON will be responsible for the procedure until one nurse on each shift is trained. o Remaining nurses will be trained and provide return demonstration by: in-service completed On: 11/01/2024 by 5 PM. Any nurse that is not trained will be trained prior to returning to their next shift. On 11/2/24 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Verified that Resident #1 was the only resident in facility with a tracheostomy. PCP notification verified on 11/2/24 by record review of a progress note documenting MD notification and record review of Resident #1's care plan indicating update occurred on 11/2/24. Record review of TAR verified that trach monitoring was now included for Resident #1. In-service regarding tracheostomy care and suctioning and respiratory therapy training was held on 11/2/24 at 6 am and was signed by DON (instructor) and LVN C In-services on tracheostomy care and suctioning and respiratory therapy trainings were held 10/31/24 through 11/2/24, instructed by DON and attended by 14 licensed nurses. Return demonstration on dummy setup observed on 11/2/24 with 7 nurses in facility. At least one nurse from each shift. Observations and interviews on 11/2/24 between the hours of 12:00 pm and 2:45 pm Licensed nurses (LVN C, LVN G, LVN J, LVN L, LVN M, and LVN N) were observed performing a verbal return demonstration on a dummy setup and were able to verbalize procedure was a sterile technique and demonstrate sterile technique via return demonstration on dummy set-up. LVN C, LVN G, LVN J, LVN L, LVN M, and LVN N said they were in-serviced on tracheostomy care and suctioning. They said they would never use any water other than sterile water and would use intermittent suctioning and never continuous suctioning. Observation on 11/2/24 at 1:00 pm the DON was observed performing appropriate tracheostomy care and suctioning on Resident #1 with no breaks in infection control or sterile technique. She wore appropriate PPE, used sterile water in sterile water container, and appropriately used intermittent suctioning. On 11/2/24 at 3:02 pm the DON was informed the IJ was removed; however, the facility remained out of compliance at a scope of no actual harm with potential for more than minimal harm that is not immediate jeopardy and scope of isolated due to the facility's need to monitor and evaluate the effectiveness of their corrective systems.

Based on observation, interview, and record review, the facility failed to prevent neglect and implement their written policies and procedures to prohibit and prevent neglect for 1 of 5 residents reviewed for neglect. (Resident #1) The facility did not provide the required supervision and a required wheelchair wedge cushion for Resident #1 who was known to be at high risk for falls due to her impulsivity and decreased safety awareness. Resident #1 was left unsupervised in her wheelchair without a wedge cushion. She was found on the floor with a head injury. She died 6 days later in the hospital as a result of her injuries. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective measures. This failure could place 15 residents on the secured unit who used wheelchairs at risk of falls with serious injuries. Findings included: A face sheet dated [DATE] indicated Resident #1, admitted on [DATE], was a [AGE] year-old female with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 was severely cognitively impaired. The MDS indicated Resident #1 had inattention and disorganized thinking that would come and go and changed in severity. The MDS indicated Resident #1 required extensive assistance of one staff with transfers, walking and locomotion. The MDS indicated Resident #1 was unable to stabilize herself without staff assistance when moving from a seated to standing position, walking, turning around, and moving on and off the toilet and surface to surface transfers. A care plan initiated on [DATE] and revised on [DATE] indicated Resident #1 was at high risk for falls due to her being unaware of safety needs, confusion, psychoactive drug use, wandering, and gait/balance problems. The incident reports for Resident #1 indicated the following falls: [DATE] at 10:26 a.m., Resident found on floor at end of hallway (no injuries, un-witnessed); [DATE] at 1:39 p.m., Resident attempted to stand at the end of hallway by the door when fell out of wheelchair (no injuries, un-witnessed); [DATE] at 6:51 a.m., Resident sitting on the floor in bedroom near bedroom door (skin tear to left antecubital, un-witnessed); [DATE] at 1:49 p.m., Resident found on floor by CNA. Resident was scooting on floor (no injuries, un-witnessed); [DATE] at 2:00 p.m., Resident found on floor scooting towards wheelchair when staff passed by her (no injuries, un-witnessed); [DATE] at 6:27 p.m., Resident sitting on floor reaching for puzzle pieces (no injuries, statement dated [DATE] indicated Resident had been sitting in wheelchair, reached for puzzle pieces and fell to floor); [DATE] at 9:15 p.m., Resident sitting on floor with her back against another bed (skin tear left elbow, un-witnessed) [DATE] at 3:45 p.m., Resident found sitting on floor next to another bed (no injuries, un-witnessed); [DATE] at 4:18 p.m., Resident fell in bathroom (no injuries, un-witnessed); [DATE] at 6:15 p.m., Resident found lying on floor in room on right side. Resident was noted to have hematoma to top of scalp and skin tear to left elbow. Resident was sent out to the local hospital; [DATE] at 7:15 p.m., Resident found on floor in room on mat lying against the bed (no injuries, un-witnessed); [DATE] at 7:23 p.m., Resident found sitting on floor on fall mat in room (no injuries, un-witnessed); and [DATE] at 8:20 p.m., Resident found in dining room on the floor sitting in front of wheelchair (no injuries, un-witnessed), An incident report dated [DATE] at 6:30 p.m., indicated a nurse heard Resident #1 yell out. The resident was found in the dining room lying on floor with a skin tear to her left elbow. The fall was un-witnessed. A care plan dated [DATE] addressed Resident #1's fall with interventions to include .continue low bed, scoop mattress, wedge cushion in wheelchair, 30 minutes checks, and every two hour toileting schedule . A fall nursing note dated [DATE] at 6:45 p.m., included check off boxes for the nurse to indicate fall interventions in place, none were checked and the box indicating no interventions was checked. An incident report dated [DATE] at 4:00 p.m., indicated Resident #1 was found on the floor next to her bed. The fall was un-witnessed with no injuries. An initial fall nurse note date [DATE] at 4:00 p.m., indicated there were no fall interventions in place. A care plan dated [DATE] addressed Resident #1's fall with interventions to include .continue low bed, scoop mattress, wedge cushion in wheelchair, 30 minute checks, and every two hour toileting schedule . An incident report dated [DATE] at 6:45 p.m., indicated Resident #1 fell in dining area. The fall was witnessed by staff who tried to get to the resident as she was falling. Resident #1 received a skin tear to left hand. A care plan dated [DATE] addressed Resident #1's fall with interventions to include . continue all interventions and 30 minute checks with every 2 hours scheduled toileting. Other interventions included anticipate resident's needs and inspect wheelchair to see if dropping the back would be appropriate . A fall nursing note dated [DATE] at 9:00 a.m., indicated Resident #1 fall intervention was a floor mat. There were no other interventions indicated. An incident report dated [DATE] at 2:49 p.m., indicated a MA was making rounds and found Resident #1 lying on the floor and she reported the incident to LVN B. LVN B indicated Resident #1 was lying on floor on her left side, next to her roommate's bed with head facing window and her feet facing the doorway. The report indicated Resident #1 had bruising to her face, laceration to face and skin tear to left elbow. The report indicated Resident #1 was sent out to the local hospital. A nursing progress note for Resident #1 dated [DATE] at 4:35 p.m., indicated a CNA found Resident #1 lying on the floor in her room with her wheelchair nearby. The note indicated when LVN B entered Resident #1's room, Resident #1 was moving around on the floor. Resident #1's left side of face was swollen and she had a skin tear to her left elbow. The note indicated Resident #1 was awake and breathing, but unable to respond to any commands. The nurse called 911, the physician, family, administrator and DON. Resident #1 was taken to the local hospital. The facility investigation report summary dated [DATE] indicated Resident #1 had an un-witnessed fall on [DATE] that resulted in an injury. Resident #1 had a long history of falls and had fall interventions in place at the time of the incident. The report indicated Resident # 1 was impulsive and lacked safety awareness. When assessed Resident #1 was awake, breathing, but unable to respond to verbal commands. Oxygen was applied to improve cognition and was sent out to the local hospital. The hospital records dated [DATE] at 3:27 p.m., Resident #1 arrived at the hospital unconscious. The notes indicated a computerized tomography (CT) scan was done that indicated a large subdural hematoma. (collection of blood outside of a blood vessel) The records indicated Resident #1 was intubated at 3:43 p.m., and that CT results were discussed with the neurosurgeon and radiologist and it was agreed that the injury was not survivable. A document from the local inpatient hospice service indicated Resident #1 expired on [DATE] at 7:55 a.m. During a telephone interview on [DATE] at 9:00 a.m., MA C said she was working the day of the incident. ([DATE]) She said she walked by Resident # 1's room and the resident was lying on the floor. She said she immediately went and told the charge nurse. She said she worked with Resident # 1 and Resident # 1 was very impulsive. She said Resident # 1 had to be constantly supervised due to her standing and attempting to walk without assistance. She said Resident # 1 was not safe to be left alone in her room while she was in her wheelchair. She said Resident # 1 had no special equipment on wheelchair or special precaution while in wheelchair to prevent her from falling. During an interview with on [DATE] at 11:00 a.m., LVN A said she was working the day of the incident. LVN A said she had taken Resident # 1 to her room to do wound care at approximately 2:00 p.m She said after completing wound care for Resident # 1 she told the resident to follow her. LVN A said she saw the oncoming nurse (LVN B) and went to give report leaving Resident #1 behind in her room. LVN A said she did not ensure Resident # 1 came out of room behind her. LVN A said Resident # 1 was sitting in her wheelchair and was still in her room when she left out. She said she was standing at the medication cart with LVN B when MA C came and told LVN B, Resident # 1 was on the floor in her room, with the wheelchair nearby. She said Resident # 1 was found on the floor by the bed in her room. LVN A said she felt Resident # 1 would be safe while alone in her room even though Resident # 1 had a history of [REDACTED]. During an interview on [DATE] at 3:00 p.m., LVN B said when she arrived to work on [DATE] at approximately 2:30 p.m., LVN A had Resident # 1 in her room performing wound care. She said at approximately 2:30 p.m., LVN A came out of Resident # 1's room and Resident # 1 was sitting in the doorway of her room. LVN B said at approximately at 2:40 p.m., MA C reported that Resident # 1 had fallen. She said Resident # 1's door was closed when she was found by the CNA. Another resident was present in the room. She said Resident # 1 was lying on her left side on the floor. She said there was blood on the floor and Resident # 1 left side of her face was swollen and left eye was swollen shut. LVN B said LVN A went to retrieve the crash cart and call 911. LVN B said Resident #1 was alert, breathing, but not responding to verbal commands. She said the AED was applied and said no shock was required. She said LVN A applied a pressure dressing to skin tear to left elbow. LVN B said oxygen was applied to Resident # 1 and Resident # 1 was moving around on the floor. She said Resident # 1 was sent out to the local hospital by ambulance at 3:03 p.m. (approximately 23 minutes after being found on floor) LVN B said Resident # 1 was at high risk for falls and staff had started doing every 30 minutes checks on Resident # 1. LVN B said Resident # 1 had to be constantly monitored, and staff had to keep her within eye sight. She said Resident # 1 was not safe to be left in room in wheelchair without staff monitoring her. She said Resident # 1 was impulsive and would often stand up from her wheelchair and attempt to walk without assistance. She said Resident # 1 could walk short distances with assistance of staff, but was too unsteady alone. During a telephone interview on [DATE] at 2:51 p.m., the previous DON said she worked at the facility from [DATE]-[DATE]. She said most of Resident #1's previous falls had been from her wheelchair. The previous DON said the staff called her for all incidents. She said staff knew Resident #1 needed to be supervised because she attempted to stand and walk. The previous DON said the nurse should have made sure Resident #1 came out the room after care was provided because of the resident's unpredictability and her previous fall from the wheelchair. She said staff knew Resident #1 was at high risk for falls and should have made it a priority to watch her at all times if possible. She said, It is a shame because if the nurse made sure she came out of the room. This might have not happened and maybe staff would have seen her and prevented it from happening. During an interview on [DATE] at 11:30 a.m., MA D said Resident # 1 could stand, but could not walk without assistance. She said Resident # 1 had a lot of falls and staff would constantly have to watch her. MA D said Resident # 1 could not be left alone in her room in her wheelchair because she was impulsive and would stand up and attempt to walk alone. She said on [DATE], at approximately 2:00 p.m., LVN A took Resident # 1 to her room and she did not see LVN A bring Resident # 1 out when LVN A came out of the room. During an observation and interviews with LVNs A and B on [DATE] at 3:30 p.m., there was a low bed with a scoop mattress and a fall mat in Resident #1's room. A wheelchair with a pressure relieving cushion (not a wedge) and a half tray attached to right arm of wheelchair. LVNs A and B said the bed and wheelchair was the same equipment used by Resident #1 while she was in the facility. LVNs A and B said the pressure relieving cushion in Resident #1's wheelchair was the same cushion used in Resident #1's wheelchair while she was in the facility. They said the cushion was not a wedge cushion as was necessary and may have prevented Resident #1 from getting out of her wheelchair. During an interview on [DATE] at 12:25 p.m., CNA E said Resident # 1 had to be constantly watched because she tried and stand up and walk. CNA E said Resident # 1 had a lot of falls and was not safe to be left in her room alone while in her wheelchair. CNA E said Resident # 1 did not stay in her room a lot and staff would provide care for her and bring her out of her room when they finished providing care because she had to be constantly watched. She said no one told her Resident # 1 had to be constantly watched, but staff just knew because Resident # 1 was impulsive and had so many falls. She did not know if Resident # 1 had any equipment in her wheelchair or special precautions while in her wheelchair to prevent falls. She said she had a cushion in her chair, but it was a regular cushion, not a wedge cushion. During an interview on [DATE] at 12:40 p.m., the ADON said Resident # 1 was very impulsive and had lots of falls. The ADON said staff provided every 30 minutes checks for Resident #1 due to falls. She said Resident # 1 would not be safe to be left in room unattended in her wheelchair. She was not sure if Resident # 1 had been put on a toileting schedule. She said therapy had worked with Resident #1 and was unsure of any special precautions that were in place for fall prevention while Resident # 1 was in her wheelchair. She said wedge cushions were available and were kept in her office. During an interview on [DATE] at 1:00 p.m., the OT said Resident # 1 was very impulsive and would stand up in wheelchair and try to walk without assistance. She said Resident # 1 was cognitively impaired and could not remember to lock her wheelchair brakes or that she could not walk without assistance. She said Resident # 1 had a half lap tray that staff was to put on her wheelchair. The OT said staff was not always compliant with putting the lap tray on Resident #1's wheelchair. She said staff had been educated on Resident # 1's need for increased supervision due to her being impulsive and standing up and attempting to walk. She said Resident # 1 had a lot of falls. The OT said Resident #1 was discontinued from therapy because she could no longer follow directions due to severe cognition deficit. She said Resident # 1 was not safe to be left unattended in her room while in her wheelchair. During an interview on [DATE] at 4:05 p.m., CNA F said Resident # 1 had to have constant supervision because she had lots of falls. CNA F said Resident # 1 was very impulsive and attempted to stand and walk. She said staff had to keep Resident #1 in eye sight. She said Resident # 1 was not safe to be left alone in her wheelchair in her room. The CNA said after staff provided care for her in her room, they would bring her out of her room because she would try to stand and walk. CNA F said Resident # 1 did not have a special cushion in her wheelchair or precautions while she was in her wheelchair to prevent falls. CNA F said staff was not instructed on fall precautions for Resident #1 they just knew she needed constant supervision because the resident fell alot. CNA F said Resident # 1 could only be left in her room alone when she put the resident in bed, but staff had to check on her frequently, even then. During an interview on [DATE] at 4:15 p.m., CNA G said Resident # 1 required constant supervision and was not safe to be left alone in her room in her wheelchair. She said the staff kept Resident # 1 in the dining area where she could be watched and was only taken to her room for care to be provided. CNA G said once care was provided, the staff would bring Resident # 1 out of her room. She said Resident # 1 was left in her room alone only when she was put to bed and staff still had to check on her frequently. She said Resident #1 did not have any special cushion in her wheelchair to prevent her from falling or special equipment. During an interview on [DATE] at 3:22 p.m., LVN H said she worked with Resident #1. She said Resident #1 always stood up from her wheelchair. She said she would sit Resident #1 near her so that she could remind her to stay seated in the wheelchair. She said Resident #1 was not safe to be left sitting in her wheelchair alone in her room. LVN H said Resident #1 was only safe to be left alone in her room, when she was sleeping. She said Resident #1 did not have a special cushion for her wheelchair to prevent her for falling. During an interview on [DATE] at 11:00 a.m., the administrator said Resident # 1 had a history of [REDACTED].# 1 had a fall and was sent to the local hospital. The administrator said in reviewing the video footage at the time of the fall the footage LVN A left Resident # 1 in her room after taking her to the room. He said the video footage showed Resident # 1 was not checked on for approximately 20 minutes, until CNAs checked on her. He said staff had been instructed to conduct 30 minutes checks on Resident # 1 prior to the incident due to her potential for falls. The administrator said he expected staff to keep Resident # 1 where they could visually see her. He said Resident # 1 would not have been safe to be left alone in her wheelchair in her room unless staff would be able to visually see her or staff was putting her to bed. An interpretation and Implementation of investigating allegations of Neglect with revision date of [DATE] indicated: .Policy Interpretation and Implementation: 1. Neglect is define as failure to provide goods and services necessary to avoid physical harm, mental anguish, meatal illness or the deterioration of a Resident's physical or mental condition. 2. Neglect also means the failure to protect the resident from abuse, neglect or exploitation 3. Neglect is repeated conduct or single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death. When investigating neglect, implement the following protocol: a. Determine what goods or services were not provided to the resident b. Determine if physical harm, mental anguish , mental illness or deterioration in the resident's physical or mental condition resulted in the failure of the facility to provide goods and services ; and c. Determine if the intend of the negligence was willful . The administrator and Regional Director of Operations were notified on [DATE] at 12:40 p.m., that an Immediate Jeopardy was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 4:30 p.m., and included: .1. Medial Director, (Dr. Khorenhekimian,) has been notified of the Immediate Jeopardy by the Administrator at 1:30pm on [DATE]. The Medical Director has been involved since notification. 2. In-service have been initiated by the Administrator/DON, ADON. The in-service will continue each shift to ensure all staff have had the training below. Completed by ADM/Designee Date: [DATE] Staff will not be allowed to work until they have completed the in-services. a. In-services for Abuse/Neglect, Alternatives Appropriate for Incidents/Falls, Fall Evaluations and Prevention and Incident Accident reporting initiated. Fall matts and other fall interventions and specialty equipment will be monitored by use of the treatment record or Medication record have been done to ensure all licensed staff understand that their initials validate placement. Placement of initials for items that are not in place will be addressed through staff training or counseling as needed. Completed by: DON/ADON Date: 6/ l/17. b. All Nursing staff, Therapy, Dietary, Environmental services, Social Services and Activity Director has been in service the purpose and use of the aides Kardex to validate understanding that specialty devices such as matts, low beds, etc. are followed to ensure resident care/safety. Completed by: DON/ADON Date: [DATE]. 3. All fall risk assessments will be completed today, [DATE] to ensure accuracy and following policy and procedures for all residents. Evidence of completed Fall Assessments given to Surveyor. 4. Fall assessment will be completed upon admission/readmission, change of condition, quarterly and after falls. If the score is 10 or greater or the resident has had a fall, the resident will be referred to Therapy for safety evaluation. Completed on: [DATE] 5. A Therapy Communication form is being instituted for nursing to complete when a resident needs to be screened for therapy and when a resident has a fall. After the screen, a communication form will be generated by therapy to communicate to nursing what the resident needs. This information will be added to the Care Plan and CNA Kardex. The therapist will attend the care plan meetings to monitor that the information has been added to the Care Plan by nursing. The DON will be responsible to monitor that the interventions from therapy or implemented and are on the care plan. Monitoring will be done weekly at the Care Plan meeting. 6. The ADON, (Ashley Wood), made 100% rounds to determine who has what interventions are in place. The care plans will be updated to reflect the current interventions. After therapy, has seen the identified residents, the therapy recommendations will be communicated to the physician for orders as needed. 7. Residents without current interventions will have the appropriate interventions put in place to meet their need to prevent falls. 8. Specific intervention will be noted on care plan and nurse aide Kardex. a. DON/ADON will complete by ,[DATE]. Resident names will be given to Surveyor. Care Plans updated by IDT. Process started on [DATE]. This implementation is to ensure that all appropriate intervention are in place. b. Copies of the updated Care Plan and Kardex will be given to the surveyor to show interventions in place. 9. The Fall system will be monitored by the DON through random chart reviews to ensure care plans and aide Kardex's are current with specialty devices for accident/incident prevention. DON to review twice a week. 10. Restorative aide will monitor for placement and working order daily and complete a checklist that will be turned in daily to ADON/DON at which time will notify Administration of any issues and present to Quality Assurance Committee. Fall prevention devices will include but not be limited to: low beds, mats, anti-roll back devices, anti-tippers, bolster mattresses, etc. Our expectation will be done daily and results discuss during the Quality Assurance Committee. We will review and update as needed. 11. The Charge Nurses will have the interventions noted on their Treatment Sheet and will be asked to sign off every shift that the appropriate devices are in place. A list of fall prevention approaches will be in 24-hour book. 12. The Administrator/Director of Nurses/Assistant Director of Nurses will also verify that these items are in place daily (M-F) through daily rounds. The weekends will be monitored by the weekend manager. 13. Any identified issues will be addressed immediately upon being identified by either intervening to replace needed interventions or performing more staff training/counseling as needed to ensure compliance with fall prevention devices. Completed by: DON/ADON Date:[DATE] 4. Quality Assurance The Administrator, will ensure a monthly review to discuss the Plan of Correction and any additional corrective actions needed for additional interventions or oversight. The Medical Director will be included in each QA Meeting. Fall Assessment and prevention will be part of our orientation and ongoing In-service for all departments including the Weekend Staff. We will be having a Quality Assurance Committee today [DATE]. In attendance will be the Administrator, Director of Nursing, Assistant Director of Nursing, Corporate Director of Clinical Services, Director of Risk Management and Survey, Dietary, Therapy and Medical Director .(sic) On [DATE] the surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: During an interview on [DATE] at 10:15 a.m., the director of clinical services said all available staff had been in serviced. He said staff who had not been in-serviced would not be able allowed to work until in-serviced. He said all fall risk assessments had been completed. The director of clinical services said care plans had been updated for residents who scored 10 or higher. He said those residents had been screened by therapy. He said new therapy communication forms had been put in place and recommendations would be added to care plans and kardex. (computerized care plans for CNAs) The director of clinical services said the therapy communication forms would be monitored by the DON and ADON. He said all residents with interventions for falls were checked to ensure interventions were implemented and in place. He said the new equipment had been ordered such as wedge cushions. On [DATE] the director of clinical services presented updated fall risk assessments for all Residents residing in facility, therapy evaluation for all Residents identified as fall risk, in-services performed on [DATE] and [DATE] concerning fall prevention, abuse/neglect and updated fall policy. During observations on [DATE] between 10:25 a.m. and 11:50 a.m., residents identified on secured unit as being risk for falls had interventions in place according to their plan of care. During an interview on [DATE] at 11:10 a.m., the therapy director verified all evaluations had been done on residents at risk for falls and a new form was to be used when making recommendations to staff concerning residents. Three LVNs, one MA, four CNAs were interviewed and said they had been in- serviced on [DATE] and [DATE] on abuse/neglect, fall preventions, interventions for falls. They said fall interventions were in place and forms were being used to communicate with therapy. They could identify residents who were at risk for falls and interventions that were in place. On [DATE] at 11:58 a.m., the Regional Director of Operations was notified the Immediate Jeopardy was removed; however the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A list provided by the ADON on date [DATE] at 10:30 a.m., indicated there were 15 residents on secured unit who used wheelchairs for mobility.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 5 residents reviewed for accidents. (Resident #1) The facility did not provide the required supervision or a required wheelchair wedge cushion for Resident #1 who was known to be at high risk for falls due to her impulsivity and decreased safety awareness. Resident #1 was left unsupervised in her wheelchair without a wedge cushion. She was found on the floor with a head injury. She died 6 days later in the hospital as a result of her injuries. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective measures. This failure could place 15 residents on the secured unit who used wheelchairs at risk of falls with serious injuries. Findings included: A face sheet dated [DATE] indicated Resident #1, admitted on [DATE], was a [AGE] year-old female with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 was severely cognitively impaired. The MDS indicated Resident #1 had inattention and disorganized thinking that would come and go and changed in severity. The MDS indicated Resident #1 required extensive assistance of one staff with transfers, walking and locomotion. The MDS indicated Resident #1 was unable to stabilize herself without staff assistance when moving from a seated to standing position, walking, turning around, and moving on and off the toilet and surface to surface transfers. A care plan initiated on [DATE] and revised on [DATE] indicated Resident #1 was at high risk for falls due to her being unaware of safety needs, confusion, psychoactive drug use, wandering, and gait/balance problems. The incident reports for Resident #1 indicated the following falls: [DATE] at 10:26 a.m., Resident found on floor at end of hallway (no injuries, un-witnessed); [DATE] at 1:39 p.m., Resident attempted to stand at the end of hallway by the door when fell out of wheelchair (no injuries, un-witnessed); [DATE] at 6:51 a.m., Resident sitting on the floor in bedroom near bedroom door (skin tear to left antecubital, un-witnessed); [DATE] at 1:49 p.m., Resident found on floor by CNA. Resident was scooting on floor (no injuries, un-witnessed); [DATE] at 2:00 p.m., Resident found on floor scooting towards wheelchair when staff passed by her (no injuries, un-witnessed); [DATE] at 6:27 p.m., Resident sitting on floor reaching for puzzle pieces (no injuries, statement dated [DATE] indicated Resident had been sitting in wheelchair, reached for puzzle pieces and fell to floor); [DATE] at 9:15 p.m., Resident sitting on floor with her back against another bed (skin tear left elbow, un-witnessed) [DATE] at 3:45 p.m., Resident found sitting on floor next to another bed (no injuries, un-witnessed); [DATE] at 4:18 p.m., Resident fell in bathroom (no injuries, un-witnessed); [DATE] at 6:15 p.m., Resident found lying on floor in room on right side. Resident was noted to have hematoma to top of scalp and skin tear to left elbow. Resident was sent out to the local hospital; [DATE] at 7:15 p.m., Resident found on floor in room on mat lying against the bed (no injuries, un-witnessed); [DATE] at 7:23 p.m., Resident found sitting on floor on fall mat in room (no injuries, un-witnessed); and [DATE] at 8:20 p.m., Resident found in dining room on the floor sitting in front of wheelchair (no injuries, un-witnessed), An incident report dated [DATE] at 6:30 p.m., indicated a nurse heard Resident #1 yell out. The resident was found in the dining room lying on floor with a skin tear to her left elbow. The fall was un-witnessed. A care plan dated [DATE] addressed Resident #1's fall with interventions to include .continue low bed, scoop mattress, wedge cushion in wheelchair, 30 minutes checks, and every two hour toileting schedule . A fall nursing note dated [DATE] at 6:45 p.m., indicated Resident #1 had no fall interventions in place. An incident report dated [DATE] at 4:00 p.m., indicated Resident #1 was found on the floor next to her bed. The fall was un-witnessed with no injuries. An initial fall nurse note date [DATE] at 4:00 p.m., indicated there were no fall interventions in place. A care plan dated [DATE] addressed Resident #1's fall with interventions to include .continue low bed, scoop mattress, wedge cushion in wheelchair, 30 minute checks, and every two hour toileting schedule . An incident report dated [DATE] at 6:45 p.m., indicated Resident #1 fell in dining area. The fall was witnessed by staff who tried to get to the resident as she was falling. Resident #1 received a skin tear to left hand. A care plan dated [DATE] addressed Resident #1's fall with interventions to include . continue all interventions and 30 minute checks with every 2 hours scheduled toileting. Other interventions included anticipate resident's needs and inspect wheelchair to see if dropping the back would be appropriate . A fall nursing note dated [DATE] at 9:00 a.m., indicated Resident #1 fall intervention was a floor mat. There were no other interventions indicated. An incident report dated [DATE] at 2:49 p.m., indicated a MA was making rounds and found Resident #1 lying on the floor and she reported the incident to LVN B. LVN B indicated Resident #1 was lying on floor on her left side, next to her roommate's bed with head facing window and her feet facing the doorway. The report indicated Resident #1 had bruising to her face, laceration to face and skin tear to left elbow. The report indicated Resident #1 was sent out to the local hospital. A nursing progress note for Resident #1 dated [DATE] at 4:35 p.m., indicated a CNA found Resident #1 lying on the floor in her room with her wheelchair nearby. The note indicated when LVN B entered Resident #1's room, Resident #1 was moving around on the floor. Resident #1's left side of face was swollen and she had a skin tear to her left elbow. The note indicated Resident #1 was awake and breathing, but unable to respond to any commands. The nurse called 911, the physician, family, administrator and DON. Resident #1 was taken to the local hospital. The facility investigation report summary dated [DATE] indicated Resident #1 had an un-witnessed fall on [DATE] that resulted in an injury. Resident #1 had a long history of falls and had fall interventions in place at the time of the incident. The report indicated Resident # 1 was impulsive and lacked safety awareness. When assessed Resident #1 was awake, breathing, but unable to respond to verbal commands. Oxygen was applied to improve cognition and was sent out to the local hospital. The hospital records dated [DATE] at 3:27 p.m., Resident #1 arrived at the hospital unconscious. The notes indicated a computerized tomography (CT) scan was done that indicated a large subdural hematoma. (collection of blood outside of a blood vessel) The records indicated Resident #1 was intubated at 3:43 p.m., and that CT results were discussed with the neurosurgeon and radiologist and it was agreed that the injury was not survivable. A document from the local inpatient hospice service indicated Resident #1 expired on [DATE] at 7:55 a.m. During a telephone interview on [DATE] at 9:00 a.m., MA C said she was working the day of the incident. ([DATE]) She said she walked by Resident # 1's room and the resident was lying on the floor. She said she immediately went and told the charge nurse. She said she worked with Resident # 1 and Resident # 1 was very impulsive. She said Resident # 1 had to be constantly supervised due to her standing and attempting to walk without assistance. She said Resident # 1 was not safe to be left alone in her room while she was in her wheelchair. She said Resident # 1 had no special equipment on wheelchair or special precaution while in wheelchair to prevent her from falling. During an interview with on [DATE] at 11:00 a.m., LVN A said she was working the day of the incident. LVN A said she had taken Resident # 1 to her room to do wound care at approximately 2:00 p.m She said after completing wound care for Resident # 1 she told the resident to follow her. LVN A said she saw the oncoming nurse (LVN B) and went to give report leaving Resident #1 behind in her room. LVN A said she did not ensure Resident # 1 came out of room behind her. LVN A said Resident # 1 was sitting in her wheelchair and was still in her room when she left out. She said she was standing at the medication cart with LVN B when MA C came and told LVN B, Resident # 1 was on the floor in her room, with the wheelchair nearby. She said Resident # 1 was found on the floor by the bed in her room. LVN A said she felt Resident # 1 would be safe while alone in her room even though Resident # 1 had a history of [REDACTED]. During an interview on [DATE] at 3:00 p.m., LVN B said when she arrived to work on [DATE] at approximately 2:30 p.m., LVN A had Resident # 1 in her room performing wound care. She said at approximately 2:30 p.m., LVN A came out of Resident # 1's room and Resident # 1 was sitting in the doorway of her room. LVN B said at approximately at 2:40 p.m., MA C reported that Resident # 1 had fallen. She said Resident # 1's door was closed when she was found by the CNA. Another resident was present in the room. She said Resident # 1 was lying on her left side on the floor. She said there was blood on the floor and Resident # 1 left side of her face was swollen and left eye was swollen shut. LVN B said LVN A went to retrieve the crash cart and call 911. LVN B said Resident #1 was alert, breathing, but not responding to verbal commands. She said the AED was applied and said no shock was required. She said LVN A applied a pressure dressing to skin tear to left elbow. LVN B said oxygen was applied to Resident # 1 and Resident # 1 was moving around on the floor. She said Resident # 1 was sent out to the local hospital by ambulance at 3:03 p.m. (approximately 23 minutes after being found on floor) LVN B said Resident # 1 was at high risk for falls and staff had started doing every 30 minutes checks on Resident # 1. LVN B said Resident # 1 had to be constantly monitored, and staff had to keep her within eye sight. She said Resident # 1 was not safe to be left in room in wheelchair without staff monitoring her. She said Resident # 1 was impulsive and would often stand up from her wheelchair and attempt to walk without assistance. She said Resident # 1 could walk short distances with assistance of staff, but was too unsteady alone. During a telephone interview on [DATE] at 2:51 p.m., the previous DON said she worked at the facility from [DATE]-[DATE]. She said most of Resident #1's previous falls had been from her wheelchair. The previous DON said the staff called her for all incidents. She said staff knew Resident #1 needed to be supervised because she attempted to stand and walk. The previous DON said the nurse should have made sure Resident #1 came out the room after care was provided because of the resident's unpredictability and her previous fall from the wheelchair. She said staff knew Resident #1 was at high risk for falls and should have made it a priority to watch her at all times if possible. She said, It is a shame because if the nurse made sure she came out of the room. This might have not happened and maybe staff would have seen her and prevented it from happening. During an interview on [DATE] at 11:30 a.m., MA D said Resident # 1 could stand, but could not walk without assistance. She said Resident # 1 had a lot of falls and staff would constantly have to watch her. MA D said Resident # 1 could not be left alone in her room in her wheelchair because she was impulsive and would stand up and attempt to walk alone. She said on [DATE], at approximately 2:00 p.m., LVN A took Resident # 1 to her room and she did not see LVN A bring Resident # 1 out when LVN A came out of the room. During an observation and interviews with LVNs A and B on [DATE] at 3:30 p.m., there was a low bed with a scoop mattress and a fall mat in Resident #1's room. A wheelchair with a pressure relieving cushion (not a wedge) and a half tray attached to right arm of wheelchair. LVNs A and B said the bed and wheelchair was the same equipment used by Resident #1 while she was in the facility. LVNs A and B said the pressure relieving cushion in Resident #1's wheelchair was the same cushion used in Resident #1's wheelchair while she was in the facility. They said the cushion was not a wedge cushion as was necessary and may have prevented Resident #1 from getting out of her wheelchair. During an interview on [DATE] at 12:25 p.m., CNA E said Resident # 1 had to be constantly watched because she tried and stand up and walk. CNA E said Resident # 1 had a lot of falls and was not safe to be left in her room alone while in her wheelchair. CNA E said Resident # 1 did not stay in her room a lot and staff would provide care for her and bring her out of her room when they finished providing care because she had to be constantly watched. She said no one told her Resident # 1 had to be constantly watched, but staff just knew because Resident # 1 was impulsive and had so many falls. She did not know if Resident # 1 had any equipment in her wheelchair or special precautions while in her wheelchair to prevent falls. She said she had a cushion in her chair, but it was a regular cushion, not a wedge cushion. During an interview on [DATE] at 12:40 p.m., the ADON said Resident # 1 was very impulsive and had lots of falls. The ADON said staff provided every 30 minutes checks for Resident #1 due to falls. She said Resident # 1 would not be safe to be left in room unattended in her wheelchair. She was not sure if Resident # 1 had been put on a toileting schedule. She said therapy had worked with Resident #1 and was unsure of any special precautions that were in place for fall prevention while Resident # 1 was in her wheelchair. She said wedge cushions were available and were kept in her office. During an interview on [DATE] at 1:00 p.m., the OT said Resident # 1 was very impulsive and would stand up in wheelchair and try to walk without assistance. She said Resident # 1 was cognitively impaired and could not remember to lock her wheelchair brakes or that she could not walk without assistance. She said Resident # 1 had a half lap tray that staff was to put on her wheelchair. The OT said staff was not always compliant with putting the lap tray on Resident #1's wheelchair. She said staff had been educated on Resident # 1's need for increased supervision due to her being impulsive and standing up and attempting to walk. She said Resident # 1 had a lot of falls. The OT said Resident #1 was discontinued from therapy because she could no longer follow directions due to severe cognition deficit. She said Resident # 1 was not safe to be left unattended in her room while in her wheelchair. During an interview on [DATE] at 4:05 p.m., CNA F said Resident # 1 had to have constant supervision because she had lots of falls. CNA F said Resident # 1 was very impulsive and attempted to stand and walk. She said staff had to keep Resident #1 in eye sight. She said Resident # 1 was not safe to be left alone in her wheelchair in her room. The CNA said after staff provided care for her in her room, they would bring her out of her room because she would try to stand and walk. CNA F said Resident # 1 did not have a special cushion in her wheelchair or precautions while she was in her wheelchair to prevent falls. CNA F said staff was not instructed on fall precautions for Resident #1 they just knew she needed constant supervision because the resident fell alot. CNA F said Resident # 1 could only be left in her room alone when she put the resident in bed, but staff had to check on her frequently, even then. During an interview on [DATE] at 4:15 p.m., CNA G said Resident # 1 required constant supervision and was not safe to be left alone in her room in her wheelchair. She said the staff kept Resident # 1 in the dining area where she could be watched and was only taken to her room for care to be provided. CNA G said once care was provided, the staff would bring Resident # 1 out of her room. She said Resident # 1 was left in her room alone only when she was put to bed and staff still had to check on her frequently. She said Resident #1 did not have any special cushion in her wheelchair to prevent her from falling or special equipment. During an interview on [DATE] at 3:22 p.m., LVN H said she worked with Resident #1. She said Resident #1 always stood up from her wheelchair. She said she would sit Resident #1 near her so that she could remind her to stay seated in the wheelchair. She said Resident #1 was not safe to be left sitting in her wheelchair alone in her room. LVN H said Resident #1 was only safe to be left alone in her room, when she was sleeping. She said Resident #1 did not have a special cushion for her wheelchair to prevent her for falling. During an interview on [DATE] at 11:00 a.m., the administrator said Resident # 1 had a history of [REDACTED].# 1 had a fall and was sent to the local hospital. The administrator said in reviewing the video footage at the time of the fall the footage LVN A left Resident # 1 in her room after taking her to the room. He said the video footage showed Resident # 1 was not checked on for approximately 20 minutes, until CNAs checked on her. He said staff had been instructed to conduct 30 minutes checks on Resident # 1 prior to the incident due to her potential for falls. The administrator said he expected staff to keep Resident # 1 where they could visually see her. He said Resident # 1 would not have been safe to be left alone in her wheelchair in her room unless staff would be able to visually see her or staff was putting her to bed. An interpretation and Implementation of investigating allegations of Neglect with revision date of [DATE] indicated: .Policy Interpretation and Implementation: 1. Neglect is define as failure to provide goods and services necessary to avoid physical harm, mental anguish, meatal illness or the deterioration of a Resident's physical or mental condition. 2. Neglect also means the failure to protect the resident from abuse, neglect or exploitation 3. Neglect is repeated conduct or single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death. When investigating neglect, implement the following protocol: a. Determine what goods or services were not provided to the resident b. Determine if physical harm, mental anguish , mental illness or deterioration in the resident's physical or mental condition resulted in the failure of the facility to provide goods and services ; and c. Determine if the intend of the negligence was willful . The administrator and Regional Director of Operations were notified on [DATE] at 12:40 p.m., that an Immediate Jeopardy was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 4:30 p.m., and included: .1. Medial Director, (Dr. Khorenhekimian,) has been notified of the Immediate Jeopardy by the Administrator at 1:30pm on [DATE]. The Medical Director has been involved since notification. 2. In-service have been initiated by the Administrator/DON, ADON. The in-service will continue each shift to ensure all staff have had the training below. Completed by ADM/Designee Date: [DATE] Staff will not be allowed to work until they have completed the in-services. a. In-services for Abuse/Neglect, Alternatives Appropriate for Incidents/Falls, Fall Evaluations and Prevention and Incident Accident reporting initiated. Fall matts and other fall interventions and specialty equipment will be monitored by use of the treatment record or Medication record have been done to ensure all licensed staff understand that their initials validate placement. Placement of initials for items that are not in place will be addressed through staff training or counseling as needed. Completed by: DON/ADON Date: 6/ l/17. b. All Nursing staff, Therapy, Dietary, Environmental services, Social Services and Activity Director has been in service the purpose and use of the aides Kardex to validate understanding that specialty devices such as matts, low beds, etc. are followed to ensure resident care/safety. Completed by: DON/ADON Date: [DATE]. 3. All fall risk assessments will be completed today, [DATE] to ensure accuracy and following policy and procedures for all residents. Evidence of completed Fall Assessments given to Surveyor. 4. Fall assessment will be completed upon admission/readmission, change of condition, quarterly and after falls. If the score is 10 or greater or the resident has had a fall, the resident will be referred to Therapy for safety evaluation. Completed on: [DATE] 5. A Therapy Communication form is being instituted for nursing to complete when a resident needs to be screened for therapy and when a resident has a fall. After the screen, a communication form will be generated by therapy to communicate to nursing what the resident needs. This information will be added to the Care Plan and CNA Kardex. The therapist will attend the care plan meetings to monitor that the information has been added to the Care Plan by nursing. The DON will be responsible to monitor that the interventions from therapy or implemented and are on the care plan. Monitoring will be done weekly at the Care Plan meeting. 6. The ADON, (Ashley Wood), made 100% rounds to determine who has what interventions are in place. The care plans will be updated to reflect the current interventions. After therapy, has seen the identified residents, the therapy recommendations will be communicated to the physician for orders as needed. 7. Residents without current interventions will have the appropriate interventions put in place to meet their need to prevent falls. 8. Specific intervention will be noted on care plan and nurse aide Kardex. a. DON/ADON will complete by ,[DATE]. Resident names will be given to Surveyor. Care Plans updated by IDT. Process started on [DATE]. This implementation is to ensure that all appropriate intervention are in place. b. Copies of the updated Care Plan and Kardex will be given to the surveyor to show interventions in place. 9. The Fall system will be monitored by the DON through random chart reviews to ensure care plans and aide Kardex's are current with specialty devices for accident/incident prevention. DON to review twice a week. 10. Restorative aide will monitor for placement and working order daily and complete a checklist that will be turned in daily to ADON/DON at which time will notify Administration of any issues and present to Quality Assurance Committee. Fall prevention devices will include but not be limited to: low beds, mats, anti-roll back devices, anti-tippers, bolster mattresses, etc. Our expectation will be done daily and results discuss during the Quality Assurance Committee. We will review and update as needed. 11. The Charge Nurses will have the interventions noted on their Treatment Sheet and will be asked to sign off every shift that the appropriate devices are in place. A list of fall prevention approaches will be in 24-hour book. 12. The Administrator/Director of Nurses/Assistant Director of Nurses will also verify that these items are in place daily (M-F) through daily rounds. The weekends will be monitored by the weekend manager. 13. Any identified issues will be addressed immediately upon being identified by either intervening to replace needed interventions or performing more staff training/counseling as needed to ensure compliance with fall prevention devices. Completed by: DON/ADON Date:[DATE] 4. Quality Assurance The Administrator, will ensure a monthly review to discuss the Plan of Correction and any additional corrective actions needed for additional interventions or oversight. The Medical Director will be included in each QA Meeting. Fall Assessment and prevention will be part of our orientation and ongoing In-service for all departments including the Weekend Staff. We will be having a Quality Assurance Committee today [DATE]. In attendance will be the Administrator, Director of Nursing, Assistant Director of Nursing, Corporate Director of Clinical Services, Director of Risk Management and Survey, Dietary, Therapy and Medical Director .(sic) On [DATE] it was confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: During an interview on [DATE] at 10:15 a.m., the director of clinical services said all available staff had been in serviced. He said staff who had not been in-serviced would not be able allowed to work until in-serviced. He said all fall risk assessments had been completed. The director of clinical services said care plans had been updated for residents who scored 10 or higher. He said those residents had been screened by therapy. He said new therapy communication forms had been put in place and recommendations would be added to care plans and kardex. (computerized care plans for CNAs) The director of clinical services said the therapy communication forms would be monitored by the DON and ADON. He said all residents with interventions for falls were checked to ensure interventions were implemented and in place. He said the new equipment had been ordered such as wedge cushions. On [DATE] the director of clinical services presented updated fall risk assessments for all Residents residing in facility, therapy evaluation for all Residents identified as fall risk, in-services performed on [DATE] and [DATE] concerning fall prevention, abuse/neglect and updated fall policy. During observations on [DATE] between 10:25 a.m. and 11:50 a.m., residents identified on secured unit as being risk for falls had interventions in place according to their plan of care. During an interview on [DATE] at 11:10 a.m., the therapy director verified all evaluations had been done on residents at risk for falls and a new form was to be used when making recommendations to staff concerning residents. Three LVNs, one MA, four CNAs were interviewed and said they had been in- serviced on [DATE] and [DATE] on abuse/neglect, fall preventions, interventions for falls. They said fall interventions were in place and forms were being used to communicate with therapy. They could identify residents who were at risk for falls and interventions that were in place. On [DATE] at 11:58 a.m., the Regional Director of Operations was notified the Immediate Jeopardy was removed; however the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A list provided by the ADON on date [DATE] at 10:30 a.m., indicated there were 15 residents on secured unit who used wheelchairs for mobility.

Based on interview and record review, the facility failed to ensure all alleged violations involving neglect were reported immediately to the administrator of the facility and to other officials for 1 of 6 residents reviewed for falls. (Resident #1) LVN A did not perform an assessment or notify other staff when Resident #1 was found unresponsive on the floor. The LVN returned the resident to a feces soiled bed and no further assessment was done on that shift. Resident #1, who was diabetic and on multiple blood thinning agents, complained of headaches and was lethargic the following 2 days. On the 3rd day, he was found unresponsive and transferred to the hospital. He never regained consciousness, was diagnosed with [REDACTED]. An Immediate Jeopardy was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The failure to report Resident #1's fall and the lack of an assessment resulted in other staff not being aware of Resident #1's fall or condition, and a delay in Resident #1's medical treatment. This failure could place the 41 residents at high risk of falls at risk for delayed medical treatment. Findings included: A Resident Information Sheet documented Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with major [MEDICAL CONDITION], diabetes, [MEDICAL CONDITION], anxiety disorder, paranoid personality disorder, chronic pain, hypertension, [MEDICAL CONDITION], heart failure, [MEDICAL CONDITION], cognitive deficits following unspecified [MEDICAL CONDITION] disease, [MEDICAL CONDITIONS], unspecified convulsions, [MEDICAL CONDITION], muscle weakness, lack of coordination, and difficulty in walking. Medication orders signed [DATE] documented that Resident #1 was taking aspirin (blood thinner) 81 mg. every day for heart health and [MEDICATION NAME] (blood thinner) 75 mg. daily. A Venous Duplex Evaluation dated [DATE] documented Resident #1 was diagnosed with [REDACTED]. Physician telephone orders dated [DATE] documented the addition of [MEDICATION NAME] and [MEDICATION NAME] (blood thinners) to Resident #1's medication regimen. A Provider Investigation Report signed by the Director of Nurses on [DATE] documented that Resident #1 fell in his room on [DATE]. The report documented that the facility was unaware of Resident #1's fall until [DATE] when therapy staff reported the fall. The report documented MA B reported Resident #1's fall around 2:00 p.m. on [DATE] to LVN A, and LVN A picked Resident #1 up from his floor mat and placed him back on the bed. There was no incident report, nursing note, or assessment of the resident documented for the fall on [DATE]. The report documented Resident #1 complained of headaches on [DATE] and [DATE] and was administered Tylenol #3 which was reportedly effective. The report indicated Resident #1 was then found unresponsive to sternal rub, with fixed and dilated pupils and was sent to the hospital on [DATE] (no time stated) where he was diagnosed with [REDACTED].#1 had not fallen, but was only on the side of the bed. The report documented that when asked a second time, LVN A admitted he gave a false report the first time and acknowledged he did pick Resident #1 off the floor and put him to bed, but he said he had taken the resident's vital signs and they were okay, he had just not documented them. The investigation report documented that Resident #1 had a PT/INR result of PT 11.1 and INR 1.03 drawn [DATE]. The report stated that at the hospital, on [DATE], the resident's PT was 163.6 and the INR was 14.2. (According to http://clotcare.com/ptinr.aspx, accessed [DATE], Understanding the PT/INR: The most common INR target range for someone on [MEDICATION NAME] ([MEDICATION NAME]) is somewhere between 2.0 and 4.0. INRs of 5 or more typically are avoided because the risk of bleeding increases significantly at INRs above 5). The report documented Resident #1 was taken off the ventilator at the hospital and died at the hospital on [DATE]. A witness statement by MA B dated [DATE] documented, Friday ([DATE]) afternoon I was walking down hall and seen Resident #1 on his fall mat beside his bed. I yelled for the nurse to take action because he was on the floor. The nurse went down the hall to the room and put him back in the bed. Resident #1 was asleep the entire time. I then walked back to my hall. He was laying on his left side on floor mat. His head was under the bedside table. A witness statement by LVN A dated [DATE] documented, This nurse was called to (Resident #1's) room because resident was on the fall mat. This nurse and CMA picked up resident and put him in bed. This nurse assessed resident no injuries were noted and vitals were within normal limits. Physician reports from the hospital dated [DATE] at 3:45 a.m., 6:38 a.m., and 7:47 p.m. documented Resident #1 was found unresponsive early that morning around 3:00 a.m. at the nursing home with dried blood in his nose. The report documented Resident #1 had a history of [REDACTED]. An examination at the hospital (CT) showed Resident #1 had bilateral diffuse subdural hemorrhage (bleeding into the space between the dura/ brain cover and the brain itself). Resident #1's INR was greater than 14. (therapeutic levels range from 2.0 to 4.0) He was unresponsive and intubated on arrival to the emergency room and placed on a ventilator. The physician documented the resident's family reported he had fallen several times at the nursing home. The physician's assessment at the conclusion of the report documented, Diffuse subdural hematoma, likely secondary to anticoagulation with possible multiple falls. The patient was intubated to protect airway, very poor prognosis, is unresponsive Possible [MEDICAL CONDITIONS] .neurologist may be consulted. During a telephone interview on [DATE] at 2:35 p.m., MA B said she was walking past Resident #1's room at approximately 2:00 p.m. on Friday [DATE] when she saw Resident #1 lying on the mat on the floor by his bed and his head was under the table next to his bed. She said she told LVN A, who was at the nursing station, that Resident #1 was on the floor, and at first LVN A ignored her. She told him a second time and he came to the resident's room. MA B said LVN A came in the room and picked Resident #1 up off the floor and put the resident in his bed on top of feces that was in the bed. When asked if the resident was alert at the time, she said no, he was knocked out. She said normally, Resident #1 would be griping or yelling at staff, but he was not responsive at all. She said LVN A did not take the resident's vital signs. She said it concerned her that LVN A did not check the resident and so she asked LVN A twice, Are you sure he's okay? and LVN A said, Yeah, he's fine. She said she and LVN A left Resident #1's room at the same time. MA B said she talked to some of her co-workers about it to ask them if they thought it was weird that the nurse did not check Resident #1's vital signs. MA B said when she came to work Sunday, she was told to hold Resident #1's [MEDICATION NAME] and [MEDICATION NAME] because he was too sleepy. When discussing why she did not report her concern to the administrator or DON on [DATE], she stated I just thought the nurse would do his job. MA B said she knew she should have reported her concerns to the administrator or DON on [DATE]. During an interview on [DATE] at 4:20 p.m., CNA C said MA B told her about Resident #1's fall that weekend and how concerned she was LVN A had not assessed Resident #1 and put him in a bed that had feces on it. CNA C said MA B told her and another aide her concerns because MA B wanted their opinion about the incident. CNA C said she told MA B she should report the incident. The facility's Provider Investigation Report, signed by the DON on [DATE] documented LVN A was terminated on [DATE] from the facility. The facility's corrective actions attached to the Provider Investigation Report included an in-service titled Abuse and Neglect dated [DATE]. The attached narrative to the in-service sign in sheet focused on falls, assessment of a resident after a fall, incident reports, writing statements for incident reports, and failure to assess a resident could be considered neglect. The in-service did not address timely reporting of abuse or neglect and to whom those reports should be made. During interviews on [DATE] at 3:00 p.m. and 4:45 p.m., the DON said she knew MA B talked to other staff about her concerns, but when she interviewed her, MA B said Resident #1 was asleep when he was lifted off the floor and put into bed. The DON said she did not conclude from her interview that MA B was concerned about what she saw, and so she did not address it as a failure to report. The facility's policy titled Abuse Prevention Program revised [DATE] included the following: It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, volunteers, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of an unknown source and theft or misappropriation of resident property to the administrator or his/her designee. .Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a resident's physical or mental condition. The Social Worker (acting for the administrator) and DON were notified on [DATE] at 4:45 p.m. that an Immediate Jeopardy was identified. The facility's Plan of Removal was accepted on [DATE] at 3:05 p.m. and included: a. LVN A was terminated on [DATE]. b. LVN A's license was referred by the facility to the Board of Nurse Examiners. c. Facility Investigation was initiated [DATE]. d. Facility Medical Director was notified. e. State Agency Program manager was notified of the incident. f. An in-service was completed on the following: -Assessments, including generation of incident reports and progress notes. -Falls and requirements of documentation and assessments required post-fall. -Reporting incidents in accordance with established procedures. -Obtaining and importance of witness statements. -Thorough assessments of residents who have fallen, had a change in condition, are on blood thinners, and have co-morbidities for nursing staff initiated [DATE] -Notification of incidents to DON provided to all nurses, initiated [DATE] -Anticoagulant policy in-service to all nurses initiated [DATE] -Diabetes policy in-service provided to all nurses, initiated [DATE] -Obtaining statements from staff working the shift when the fall occurred, in-service to all nurses initiated [DATE] -Abuse/Neglect Policy and reporting suspected abuse/neglect to the abuse coordinator in-service proved to nurses, medication aides, and nurse's aides, initiated [DATE]. g. Nurses identified through daily monitoring as needing further training will be trained on assessment skill by DON/ADON/MDS coordinator as deemed necessary by DON/Admin through review of documentation of assessment on the facility software program, initiated [DATE]. 8. DON/Administrator will implement changes by reviewing documentation on the facility software program and working one on one with nurses ensuring that assessment competency is effective and appropriate, initiated [DATE]. h. DON/Administrator will monitor documentation obtained from the facility software twice daily and notify nurses with any questions or concerns initiated on [DATE] through [DATE] and ongoing for the next 30 days and after review in the Quality Assurance Committee determine if Performance Improvement Plan is indicated. Medical Director was notified on [DATE]. i. Out of cycle Quality Assurance meeting conducted by Corporate RN on [DATE]. Members were Regional Director of Operations, Medical Director, a second Corporate RN and the facility IDT. QA to review the success of this Plan of Removal monthly until QA Committee determines compliance is maintained for 3 consecutive months. On [DATE], the surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Four nurse's aides and 1 medication aide who were interviewed and said they were trained regarding immediately reporting any suspicion of abuse or neglect, the definitions of abuse and neglect, and to whom to report abuse and neglect. Eight LVNs from all shifts were interviewed and said they were trained regarding immediately reporting any suspicion of abuse or neglect, the definitions of abuse and neglect, and to whom to report abuse and neglect. Review of the facility's in-service documentation that included assessments, falls, reporting incidents, anticoagulant policy and diabetes policy. In-services were attended with direct care staff from all three shifts. An In-service regarding anicoagulation was attended by 21 nurses; An in-service for diabetes was attended by 21 nurses; An in-service for assessing falls and their causes was attended by 44 staff from all disciplines; An in-service for falls and incidents, reporting and documenting was attended by 37 staff from all disciplines; An intervice for witness statements related to incidents was attended by 34 staff from all disciplines; an inservice for abuse and neglect was attended by 37 staff from all disciplines; an in-service in change in residents condition and status was attended by 33 staff from various diciplines; an in-service on acute condition changes was attended by 33 staff from various disciplines; and in-service on the falling star program was attended by 22 staff from various disciplines. Review of the facility's actions regarding all resident falls/changes of condition [DATE] - [DATE] with the DON, confirmed each incident was addressed according to the facility's action plan. On [DATE] at 3:05 p.m., the Social Worker (acting for the administrator) was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. On [DATE] at 1:45 p.m., the DON said the facility had 41 residents at high risk for falls.

Based on interview and record review, the facility failed to implement their written policies that prohibit and prevent neglect of residents for 1 of 6 residents (Resident #1) reviewed for falls. LVN A did not perform an assessment or notify other staff when Resident #1 was found unresponsive on the floor. The LVN and a MA returned the resident to a feces soiled bed and no further assessment was done on that shift. R#1, who was diabetic and on multiple blood thinning agents, complained of headaches and was lethargic the following 2 days. On the 3rd day, he was found unresponsive and transferred to the hospital. He never regained consciousness, was diagnosed with [REDACTED]. An Immediate Jeopardy was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure resulted in a delay of medical treatment for [REDACTED]. Findings included: The facility's policy titled Abuse Prevention Program revised [DATE] included the following: It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, volunteers, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of an unknown source and theft or misappropriation of resident property to the administrator or his/her designee. .Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a resident's physical or mental condition. A Resident Information Sheet documented Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with major [MEDICAL CONDITION], diabetes, [MEDICAL CONDITION], anxiety disorder, paranoid personality disorder, chronic pain, hypertension, [MEDICAL CONDITION], heart failure, [MEDICAL CONDITION], cognitive deficits following unspecified [MEDICAL CONDITION] disease, [MEDICAL CONDITIONS], unspecified convulsions, [MEDICAL CONDITION], muscle weakness, lack of coordination, and difficulty in walking. Medication orders signed [DATE] documented that Resident #1 was taking aspirin (blood thinner) 81 mg. every day for heart health and [MEDICATION NAME] (blood thinner) 75 mg. daily. A Venous Duplex Evaluation dated [DATE] documented Resident #1 was diagnosed with [REDACTED]. Physician telephone orders dated [DATE] documented the addition of [MEDICATION NAME] and [MEDICATION NAME] (blood thinners) to Resident #1's medication regimen. A Provider Investigation Report signed by the Director of Nurses on [DATE] documented that Resident #1 fell in his room on [DATE]. The report documented that the facility was unaware of Resident #1's fall until [DATE] when therapy staff reported the fall. The report documented MA B reported Resident #1's fall around 2:00 p.m. on [DATE] to LVN A, and LVN A picked Resident #1 up from his floor mat and placed him back on the bed. There was no incident report, nursing note, or assessment of the resident documented for the fall on [DATE]. The report documented Resident #1 complained of headaches on [DATE] and [DATE] and was administered Tylenol #3 which was reportedly effective. The report indicated Resident #1 was then found unresponsive to sternal rub, with fixed and dilated pupils and was sent to the hospital on [DATE] (no time stated) where he was diagnosed with [REDACTED].#1 had not fallen, but was only on the side of the bed. The report documented that when asked a second time, LVN A admitted he gave a false report the first time and acknowledged he did pick Resident #1 off the floor and put him to bed, but he said he had taken the resident's vital signs and they were okay, he had just not documented them. The investigation report documented that Resident #1 had a PT/INR result of PT 11.1 and INR 1.03 drawn [DATE]. The report stated that at the hospital on [DATE], the resident's PT was 163.6 and the INR was 14.2. (According to http://clotcare.com/ptinr.aspx, accessed [DATE], Understanding the PT/INR: The most common INR target range for someone on [MEDICATION NAME] ([MEDICATION NAME]) is somewhere between 2.0 and 4.0. INRs of 5 or more typically are avoided because the risk of bleeding increases significantly at INRs above 5). The report documented Resident #1 was taken off the ventilator at the hospital and died at the hospital on [DATE]. A witness statement by MA B dated [DATE] documented, Friday ([DATE]) afternoon I was walking down hall and seen Resident #1 on his fall mat beside his bed. I yelled for the nurse to take action because he was on the floor. The nurse went down the hall to the room and put him back in the bed. Resident #1 was asleep the entire time. I then walked back to my hall. He was laying on his left side on floor mat. His head was under the bedside table. A witness statement by LVN A dated [DATE] documented, This nurse was called to (Resident #1's) room because resident was on the fall mat. This nurse and CMA picked up resident and put him in bed. This nurse assessed resident no injuries were noted and vitals were within normal limits. Physician reports from the hospital dated [DATE] at 3:45 a.m., 6:38 a.m., and 7:47 p.m. documented Resident #1 was found unresponsive early that morning around 3:00 a.m. at the nursing home with dried blood in his nose. The report documented Resident #1 had a history of [REDACTED]. An examination at the hospital (CT) showed Resident #1 had bilateral diffuse subdural hemorrhage (bleeding into the space between the dura/ brain cover and the brain itself). Resident #1's INR was greater than 14. (therapeutic levels range from 2.0 to 4.0 ) He was unresponsive and intubated on arrival to the emergency room and placed on a ventilator. The physician documented the resident's family reported he had fallen several times at the nursing home. The physician's assessment at the conclusion of the report documented, Diffuse subdural hematoma, likely secondary to anticoagulation with possible multiple falls. The patient was intubated to protect airway, very poor prognosis, is unresponsive Possible [MEDICAL CONDITIONS] .neurologist may be consulted. During a telephone interview on [DATE] at 2:35 p.m., MA B said she was walking past Resident #1's room at approximately 2:00 p.m. on Friday [DATE] when she saw Resident #1 lying on the mat on the floor by his bed and his head was under the table next to his bed. She said she told LVN A, who was at the nursing station, that Resident #1 was on the floor, and at first LVN A ignored her. She told him a second time and he came to the resident's room. MA B said LVN A came in the room and picked Resident #1 up off the floor and put the resident in his bed on top of feces that was in the bed. When asked if the resident was alert at the time, she said no, he was knocked out. She said normally, Resident #1 would be griping or yelling at staff, but he was not responsive at all. She said LVN A did not take the resident's vital signs. She said it concerned her that LVN A did not check the resident and so she asked LVN A twice, Are you sure he's okay? and LVN A said, Yeah, he's fine. She said she and LVN A left Resident #1's room at the same time. MA B said she talked to some of her co-workers about it to ask them if they thought it was weird that the nurse did not check Resident #1's vital signs. MA B said when she came to work Sunday, she was told to hold Resident #1's [MEDICATION NAME] and [MEDICATION NAME] because he was too sleepy. When discussing why she did not report her concern to the administrator or DON on [DATE], she stated I just thought the nurse would do his job. MA B said she knew she should have reported her concerns to the administrator or DON on [DATE]. During an interview on [DATE] at 4:20 p.m., CNA C said MA B told her about Resident #1's fall that weekend and how concerned she was LVN A had not assessed Resident #1 and put him in a bed that had feces on it. CNA C said MA B told her and another aide her concerns because MA B wanted their opinion about the incident. CNA C said she told MA B she should report the incident. The facility's Provider Investigation Report, signed by the DON on [DATE] documented LVN A was terminated on [DATE] from the facility. The facility's corrective actions attached to the Provider Investigation Report included an in-service titled Abuse and Neglect dated [DATE]. The attached narrative to the in-service sign in sheet focused on falls, assessment of a resident after a fall, incident reports, writing statements for incident reports, and failure to assess a resident could be considered neglect. The in-service did not address timely reporting of abuse or neglect and to whom those reports should be made. During interviews on [DATE] at 3:00 p.m. and 4:45 p.m., the DON said she knew MA B talked to other staff about her concerns, but when she interviewed her, MA B said Resident #1 was asleep when he was lifted off the floor and put into bed. The DON said she did not conclude from her interview that MA B was concerned about what she saw, and so she did not address it as a failure to report. The Social Worker (acting for the administrator) and DON were notified on [DATE] at 4:45 p.m. that an Immediate Jeopardy was identified. The facility's Plan of Removal was accepted on [DATE] at 3:05 p.m. and included: a. LVN A was terminated on [DATE]. b. LVN A's license was referred by the facility to the Board of Nurse Examiners. c. Facility Investigation was initiated [DATE]. d. Facility Medical Director was notified. e. State Agency Program manager was notified of the incident. f. An in-service was completed on the following: -Assessments, including generation of incident reports and progress notes. -Falls and requirements of documentation and assessments required post-fall. -Reporting incidents in accordance with established procedures. -Obtaining and importance of witness statements. -Thorough assessments of residents who have fallen, had a change in condition, are on blood thinners, and have co-morbidities for nursing staff initiated [DATE] -Notification of incidents to DON provided to all nurses, initiated [DATE] -Anticoagulant policy in-service to all nurses initiated [DATE] -Diabetes policy in-service provided to all nurses, initiated [DATE] -Obtaining statements from staff working the shift when the fall occurred, in-service to all nurses initiated [DATE] -Abuse/Neglect Policy and reporting suspected abuse/neglect to the abuse coordinator in-service proved to nurses, medication aides, and nurse's aides, initiated [DATE]. g. Nurses identified through daily monitoring as needing further training will be trained on assessment skill by DON/ADON/MDS coordinator as deemed necessary by DON/Admin through review of documentation of assessment on the facility software program, initiated [DATE]. 8. DON/Administrator will implement changes by reviewing documentation on the facility software program and working one on one with nurses ensuring that assessment competency is effective and appropriate, initiated [DATE]. h. DON/Administrator will monitor documentation obtained from the facility software twice daily and notify nurses with any questions or concerns initiated on [DATE] through [DATE] and ongoing for the next 30 days and after review in the Quality Assurance Committee determine if Performance Improvement Plan is indicated. Medical Director was notified on [DATE]. i. Out of cycle Quality Assurance meeting conducted by Corporate RN on [DATE]. Members were Regional Director of Operations, Medical Director, a second Corporate RN and the facility IDT. QA to review the success of this Plan of Removal monthly until QA Committee determines compliance is maintained for 3 consecutive months. On [DATE], the surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Four nurse's aides and 1 medication aide who were interviewed and said they were trained regarding immediately reporting any suspicion of abuse or neglect, the definitions of abuse and neglect, and to whom to report abuse and neglect. Eight LVNs from all shifts were interviewed and said they were trained regarding immediately reporting any suspicion of abuse or neglect, the definitions of abuse and neglect, and to whom to report abuse and neglect. Review of the facility's in-service documentation that included assessments, falls, reporting incidents, anticoagulant policy and diabetes policy. In-services were attended with direct care staff from all three shifts. An In-service regarding anicoagulation was attended by 21 nurses; An in-service for diabetes was attended by 21 nurses; An in-service for assessing falls and their causes was attended by 44 staff from all disciplines; An in-service for falls and incidents, reporting and documenting was attended by 37 staff from all disciplines; An intervice for witness statements related to incidents was attended by 34 staff from all disciplines; an inservice for abuse and neglect was attended by 37 staff from all disciplines; an in-service in change in residents condition and status was attended by 33 staff from various diciplines; an in-service on acute condition changes was attended by 33 staff from various disciplines; and in-service on the falling star program was attended by 22 staff from various disciplines. Review of the facility's actions regarding all resident falls/changes of condition [DATE] - [DATE] with the DON, confirmed each incident was addressed according to the facility's action plan. On [DATE] at 3:05 p.m., the Social Worker (acting for the administrator) was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. On [DATE] at 1:45 p.m., the DON said the facility had 41 residents at high risk for falls.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents reviewed for falls. (Resident #1) LVN A did not perform an assessment or notify other staff when Resident #1 was found unresponsive on the floor. The LVN and a MA returned the resident to a feces soiled bed and no further assessment was done on that shift. R#1, who was diabetic and on multiple blood thinning agents, complained of headaches and was lethargic the following 2 days. On the 3rd day, he was found unresponsive and transferred to the hospital. He never regained consciousness, was diagnosed with [REDACTED]. An Immediate Jeopardy was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure resulted in a delay of medical treatment for [REDACTED]. Findings included: A Resident Information Sheet documented Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with major [MEDICAL CONDITION], diabetes, [MEDICAL CONDITION], anxiety disorder, paranoid personality disorder, chronic pain, hypertension, [MEDICAL CONDITION], heart failure, [MEDICAL CONDITION], cognitive deficits following unspecified [MEDICAL CONDITION] disease, [MEDICAL CONDITIONS], unspecified convulsions, [MEDICAL CONDITION], muscle weakness, lack of coordination, and difficulty in walking. An MDS dated [DATE] documented Resident #1 had moderate cognitive impairment. He had physical and verbal behavioral symptoms directed toward others 4 to 6 days, but less than daily; he required extensive assistance of two persons to transfer, toilet and for personal hygiene, and extensive assistance of one person to dress. Resident #1 had an indwelling catheter and was frequently incontinent of bowel. The MDS documented Resident #1 had not had any falls since the prior assessment. Medication orders titled admission orders [REDACTED] aspirin (blood thinner) 81 mg. every day for heart health [MEDICATION NAME] (blood thinner) 75 mg. daily. [MEDICATION NAME] solution 100 unit/ml, inject as per sliding scale (,[DATE]=2 units; ,[DATE]=4 u; ,[DATE]=6 u; ,[DATE]=8 u; and ,[DATE]=10 u; above 400 give 10 u and notify MD) subcutaneously before meals and at bedtime related to diabetes mellitus type 2 [MEDICATION NAME] Solution 100 unit/ml, inject 8 units subcutaneously at bedtime related to diabetes. A Venous Duplex Evaluation dated [DATE] documented that Resident #1 was diagnosed with [REDACTED]. A physician's telephone order for Resident #1 dated [DATE] documented an order for [REDACTED]. Resident #1's care plan, revised on [DATE], documented he had five falls since [DATE]. Interventions included neuro checks; monitoring for injuries and changes in consciousness, activity level, and cognition. Another problem documented that Resident #1 was on anticoagulant/antiplatelet therapy r/t: [MEDICAL CONDITION] and [MEDICAL CONDITION] disease with a history of a stroke. Interventions included to take precautions to prevent falls. A Provider Investigation Report signed by the Director of Nurses on [DATE] documented that Resident #1 fell in his room on [DATE]. The report documented that the facility was unaware of Resident #1's fall until [DATE] when therapy staff reported the fall. The report documented that the facility determined MA B reported Resident #1's fall around 2:00 p.m. on [DATE] to LVN A, and LVN A picked Resident #1 up from his floor mat and placed him back on the bed. There was no incident report immediately following the fall, or nursing note, or assessment of the resident documented. The report documented that Resident #1 complained of headaches on [DATE] and [DATE] and was administered Tylenol #3 which was reportedly effective. The report documented that Resident #1 was then found unresponsive to sternal rub with fixed and dilated pupils and was sent to the hospital on [DATE] (no time stated) where he was diagnosed with [REDACTED].#1 had not fallen, but was only on the side of the bed. The report documented that when asked a second time, LVN A admitted he gave a false report the first time and acknowledged that he did pick Resident #1 off the floor and put him to bed, but said he had taken the resident's vital signs and they were okay, he had just not documented them. The investigation report documented that Resident #1 had a PT/INR result of PT 11.1 and INR 1.03 drawn [DATE]. The report stated that at the hospital the resident's PT was 163.6 and the INR was 14.2 (on [DATE]). The report documented Resident #1 was taken off the ventilator at the hospital and died at the hospital on [DATE]. According to http://clotcare.com/ptinr.aspx, accessed [DATE], Understanding the PT/INR: The most common INR target range for someone on [MEDICATION NAME] ([MEDICATION NAME]) is somewhere between 2.0 and 4.0. INRs of 5 or more typically are avoided because the risk of bleeding increases significantly at INRs above 5. The facility attached documentation of facility actions taken following their investigation findings which included placing a star on the outside of rooms of residents who were at high risk for falls, and in-servicing staff on abuse and neglect, assessments, falls, reporting incidents, reporting abuse, and statements. The facility documented they terminated LVN A and sent a referral to the Board of Nursing. An attached sign in sheet titled, Falls and incidents, reporting falls, and documenting appropriately documented 6 (six) nurses were in attendance at the in-service. The narrative of the in-service provided indicated that a full head to toe assessment was to be completed following a fall. The in-service did not address the elements of a thorough nursing assessment and did not address the protocol for a resident with a change in their level of consciousness. The in-service did not address checking a diabetic resident's blood sugar when a diabetic resident is found with a change in their level of consciousness. The in-service did not specify the assessment and monitoring needs of a resident who has fallen and is on anti-coagulant medications. Resident #1 Medication Administration Records for [DATE] did not contain a record of Resident #1's blood sugar at or around 2:00 p.m. when Resident #1 was found unresponsive or at or around 3:00 p.m. when therapy staff reported Resident #1's unresponsiveness. The following entries were made on [DATE] according to the prescribed schedule: 6:30 a.m. - the nurse documented a blood sugar of 185 with 2 units of insulin administered. 10:30 a.m. - the nurse documented a blood sugar of 104 with no insulin administered. 4:30 p.m.- the nurse documented a blood sugar of 204 with 4 units of insulin administered. 8:00 p.m. the blood sugar was 196 with a 3 written over the 1 for 396, and 10 units of insulin administered. Resident #1's nursing notes did not have a nursing entry on [DATE]. A nurse's note on [DATE] at 9:15 p.m. documented Resident #1 had a nosebleed, which was stopped and vital signs were normal. The nurse contacted the doctor and received an order to hold [MEDICATION NAME] and [MEDICATION NAME] and get a PT/INR in the morning. A witness statement by MA B dated [DATE] documented, Friday afternoon ([DATE]) I was walking down the hall and seen Resident #1 on his fall mat beside his bed. I yelled for the nurse to take action because he was on the floor. The nurse went down the hall to the room and put him back in the bed. Resident #1 was asleep the entire time. I then walked back to my hall. He was laying on his left side on floor mat. His head was under the bedside table. A witness statement by LVN A dated [DATE] (sic/17) documented, This nurse was called to Resident #1's room because resident was on the fall mat. This nurse and CMA picked up resident and put him in bed. This nurse assessed resident no injuries were noted and vitals were within normal limits. Physician reports from the hospital dated [DATE] at 3:45 a.m., 6:38 a.m., and 7:47 p.m. documented Resident #1 had been found unresponsive early that morning around 3:00 a.m. at the nursing home with dried blood in his nose. The report documented Resident #1 had a history of [REDACTED]. Examination at the hospital (CT) showed Resident #1 had bilateral diffuse subdural hemorrhage (bleeding into the space between the dura/ brain cover and the brain itself). Resident #1 was found with an INR greater than 14. He was unresponsive and intubated on arrival to the emergency room and placed on a ventilator. The physician documented that the resident's family reported that he had several falls at the nursing home. The physician's assessment at the conclusion of the report documented, Diffuse subdural hematoma, likely secondary to anticoagulation with possible multiple falls. The patient was intubated to protect airway, very poor prognosis, is unresponsive Possible [MEDICAL CONDITIONS] .neurologist may be consulted. During a telephone interview on [DATE] at 2:35 p.m., MA B said that she was walking past Resident #1's room at approximately 2:00 p.m. on Friday [DATE] when she saw Resident #1 lying on the mat on the floor by his bed and his head was under the table next to his bed. She said she told LVN A, who was at the nursing station, that Resident #1 was on the floor, and at first LVN A ignored her. She told him a second time and he came to the resident's room. MA B said LVN A came in the room and picked Resident #1 up off the floor and put the resident in his bed on top of feces that was in the bed. When asked if the resident was alert at the time, she said no, that he was knocked out. She said that normally, Resident #1 would be griping or yelling at staff, but he was not responsive at all. She said LVN A did not take the resident's vital signs. She said it concerned her that he did not check the resident and so she asked LVN A twice, Are you sure he's okay? and LVN A said, Yeah, he's fine. She said that she and LVN A left Resident #1's room at the same time. MA B said she talked to some of her co-workers about it to ask them if they thought it was weird that the nurse did not check Resident #1's vital signs. MA B said that when she came to work Sunday, she was told to hold Resident #1's [MEDICATION NAME] and [MEDICATION NAME] because he was too sleepy. When discussing why she did not report her concern to the Administrator or DON on [DATE], she stated I just thought the nurse would do his job. During an interview on [DATE] at 4:20 p.m., OTR D said that she was at the nurse's station writing an order when she saw MA B approach the nursing station to tell LVN A that Resident #1 was on the floor. OTR D said that others at the nursing station at the time were LVNs E and F. OTR D said she watched LVN A go to Resident #1's room and watched him return. She said he was not in the resident's room very long. She said it only took her a few minutes to write the order and he was already coming back from the room when she was getting up to leave the nursing station. OTR D said Resident #1 had been more lethargic that day ([DATE]) than normal and they had a hard time getting him up for therapy earlier. She said that about an hour after the fall, she and another therapist went to Resident #1's room to check on him. She said that Resident #1 was found lying in feces, was not responding when they tried to wake him, and was lying partially off the bed. She said they immediately went to LVN A to tell him the resident was not responding and was lying partially off the bed. She said LVN A kind of huffed, put his pen down hard and then went to the resident's room. She said she does not know what happened after that, as she and the other therapist left the hall. An occupational therapy note for Resident #1 dated [DATE] at 3:20 p.m. documented Response to session interventions: Patient with significantly increased lethargy today; pt. required max (maximum) encouragement and instruction for safe/effective task performances; decreased ability to follow simple commands and/or maintain attention to task; nsg (nursing) aware. During an interview on [DATE] at 3:55 p.m., LVN E said she was training with LVN A on [DATE] as it was only her second day on the job. LVN E said she did not see MA B report Resident #1's fall to LVN A. LVN E said she remained unaware that Resident #1 had a fall on [DATE] as LVN A never told her the resident fell . She said she was with LVN A when the two therapists reported that Resident #1 was partially off the bed. She said that LVN A went in and put Resident #1 back on the bed. LVN E said the resident was still lying in feces. She said, He'd had some kind of diarrhea. LVN E said LVN A did not assess Resident #1. She said she followed LVN A around all evening [DATE] and he never went back into Resident #1's room the remainder of the shift that ended at 10:00 p.m. LVN E said she had not had any training specific to assessing a resident after a fall, except what she may have taken on the computer. During an interview on [DATE] at 11:05 a.m., LVN F said she was getting off shift at 2:00 p.m. on [DATE] but did not remember MA B reporting Resident #1's fall. She said she worked the following Saturday and Sunday ([DATE] and [DATE]) with Resident #1. She said he stayed in bed over the weekend but that was not unusual for him. She said that both days he complained of headaches, and when she gave him the option of regular Tylenol or Tylenol #3's, he had asked for the stronger one. She said that each time, he told her the Tylenol #3 was effective. LVN F said Resident #1 did have a history of falls, but she was never made aware of the fall on [DATE]. Resident #1's Medication Administration Records for [DATE] and [DATE] showed he was administed Tylenol with [MEDICATION NAME] #3 ,[DATE] once on each day. During an interview on [DATE] at 12:00 noon, LVN G said she worked with Resident #1 the evening shift on Saturday and Sunday ([DATE] and [DATE]). She said Resident #1 seemed a little sleepy but she had been told he had stayed up late. She said on Sunday, Resident #1 had a nosebleed that took a while to stop. She called the physician and he gave orders to hold the blood thinners and for a PT/INR the next morning. LVN G said Resident #1 was found unresponsive on the night shift and sent out to the hospital. LVN G said that if she had known about Resident #1's fall on [DATE] she would have been more concerned about his drowsiness and his nosebleed. Interview attempts with LVN A by telephone on [DATE], [DATE], and [DATE] were unsuccessful. During an interview on [DATE] at 3:00 p.m. when discussing that the facility's investigation report did not address that Resident #1's blood sugar was not recorded when he was found non responsive, and the attached in-service did not address the need to check a blood sugar for a non-responsive diabetic resident, the DON stated she did not ask LVN A about checking Resident #1's blood sugar when she interviewed him during the investigation. During an interview on [DATE] at 5:30 p.m., the Administrator stated that LVN A was a well trained nurse who just had a bad lapse in judgement. When discussing that the facility's in-service only included 6 facility nurses, the Administrator looked at the in-service sheets and agreed, saying that is what it looked like. He said he did not believe those were the only nurses trained. During an interview on [DATE] at 9:30 a.m. the DON and Corporate Nurse H provided a computer printout of nurse's names who signed on to the computer message board. The DON and Corporate Nurse H explained that the same in-service that was attached to sign in sheets was also placed on the computer message board, and the nurse log-ins to the computer message board were evidence that the nurses read the information. The printout for the Facility Bulletin Board which was provided to the surveyor [DATE] at 9:30 a.m., following the identification of Immediate Jeopardy, documented a narrative entry on [DATE] that a star outside the door indicated residents were at high risk of falling. The entry documented witness statements must be taken after a fall, residents must be assessed after a fall; assessments include blood pressure, heart rate, respirations, neuro checks, range of motion, and blood sugar if the resident is a diabetic. The entry stated a three day follow up for residents after a fall was required and each shift completes neuro checks, assessing residents on anticoagulants for signs and symptoms of bleeding and any delayed injuries. The entry documented instructions for notifications to be made. Regarding Abuse and Neglect: The entry documented that all suspected abuse and neglect should be reported immediately to the Administrator or Social Worker. The attached employee log-in sheet had 23 nurses' names highlighted showing all of the log in dates for each nurse. Each nurse had logged on to the bulletin board before, on, or after [DATE], but there was no documentation as to what the nurse reviewed after logging on to the message board. A facility policy titled, Assessing Falls and Their Causes revised [DATE] provided by the DON on [DATE] included the following: After a Fall: 1. If a resident has just fallen, or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine, and extremities. .5. Nursing Staff will observe for delayed complications of a fall for approximately forty-eight hours after an observed or suspected fall, and will document findings in the medical record. 6. Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. It will note the presence or absence of significant findings. 7. An incident report must be completed for resident falls. The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing Services no later than 24 hours after the fall occurs. Under the Heading of Documentation: When a resident falls, the following information should be recorded in the resident's medical record: 1. The condition in which the resident was found . 2. Assessment data, including vital signs and any obvious injuries 3. Interventions, first aid, or treatment administered 4. Notification of the physician and family as indicated . A facility policy titled Acute Condition Changes - Clinical Protocol revised [DATE] provided by the DON on [DATE] included the following: Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the physician; for example, history of present illness and previous and recent test results for comparison. A facility policy titled Change in a Resident's Condition or Status, Revised [DATE] provided by the DON on [DATE] included the following: The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS RAI Instruction Manual. A facility policy titled, Diabetes Clinical Protocol Revised [DATE] included the following: 5. The staff will identify and report complications such as foot infections, skin ulceration, increased thirst, or [DIAGNOSES REDACTED]. a. For example, urgent notification may be indicated if the individual has not eaten well or consumed sufficient fluids for 2 or more days and has fever, [MEDICAL CONDITION], lethargy or confusion. A facility policy titled, Anticoagulation - Clinical Protocol revised on [DATE] included the following: The staff and physician will identify and address potential complications in individuals receiving anticoagulation; for example, someone with a fall risk, a history of [MEDICAL CONDITION], or poorly controlled hypertension. The Social Worker (acting for Administrator) and DON were notified on [DATE] at 4:45 p.m. that an Immediate Jeopardy was identified. The facility's Plan of Removal was accepted on [DATE] at 3:05 p.m. and included: a. LVN A was terminated on [DATE]. b. LVN A's license was referred by the facility to the Board of Nurse Examiners. c. Facility Investigation was initiated [DATE]. d. Facility Medical Director was notified. e. State Agency Program manager was notified of the incident. f. In-Service was completed on the following: -Assessments, including generation of incident reports and progress notes. -Falls and requirements of documentation and assessments required post-fall. -Reporting incidents in accordance with established procedures. -Obtaining and importance of witness statements. -Thorough assessments of residents who have fallen, had a change in condition, are on blood thinners, and have co-morbidities for nursing staff initiated [DATE] -Notification of incidents to DON provided to all nurses, initiated [DATE] -Anticoagulant policy in-service to all nurses initated [DATE] -Diabetes policy in-service provided to all nurses, initated [DATE] -Obtaining statements from staff working the shift when the fall occurred in-service to all nurses initated [DATE] -Abuse/Neglect Policy and reporting suspected abuse/neglect to the abuse coordinator in-service proved to nurses, medication aides, and nurse's aides, initiated [DATE]. g. Nurses identified through daily monitoring as needing further training will be trained on assessment skill by DON/ADON/MDS coordinator as deemed necessary by DON/Admin through review of documentation of assessment on the facility software program, initiated [DATE]. 8. DON/Administrator will implement changes by reviewing documentation on the facility software program and working one on one with nurses ensuring that assessment competency is effective and appropriate, initiated [DATE]. h. DON/Administrator will monitor documentation obtained from the facility software twice daily and notify nurses with any questions or concerns initated on [DATE] through [DATE] and ongoing for the next 30 days and after review in the Quality Assurance Committee determine if Performance Improvement Plan is indicated. Medical Director was notified on [DATE]. i. Out of cycle Quality Assurance meeting conducted by Corporate RN on [DATE]. Members were Regional Director of Operations, Medical Director, a second Corporate RN and the facility IDT. QA to review the success of this Plan of Removal monthly until QA Committee determines compliance is maintained for 3 consecutive months. On [DATE], the surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Interviews with 4 nurse's aides and 1 medication aide who said they were trained regarding immediately reporting any suspicion of abuse or neglect, the definitions of abuse and neglect, and to whom to report abuse and neglect. Interviews with 8 LVNs from all shifts who said they were trained regarding a thorough assessment of a resident following a fall, including assessment of residents with a change in condition who are taking anti-coagulants and assessment of residents who are diabetic. Review of the facility's in-service documentation that included assessments, falls, reporting incidents, anticoagulant policy and diabetes policy. In-services were attended with direct care staff from all three shifts. An In-service regarding anicoagulation was attended by 21 nurses; An in-service for diabetes was attended by 21 nurses; An in-service for assessing falls and their causes was attended by 44 staff from all disciplines; An in-service for falls and incidents, reporting and documenting was attended by 37 staff from all disciplines; An intervice for witness statements related to incidents was attended by 34 staff from all disciplines; an inservice for abuse and neglect was attended by 37 staff from all disciplines; an in-service in change in residents condition and status was attended by 33 staff from various diciplines; an in-service on acute condition changes was attended by 33 staff from various disciplines; and in-service on the falling star program was attended by 22 staff from various disciplines. Interview with the DON to confirm each incident from ,[DATE] - [DATE] was addressed according to the facility's action plan. On [DATE] at 3:05 p.m., the Social Worker (acting for Administrator) was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. On [DATE] at 1:45 p.m., the DON stated the facility had 41 residents at high risk for falls.

Based on observation, interview, and record review, the facility failed to implement their polices and procedures to prevent neglect for 1 of 6 residents reviewed for neglect. (Resident #62) The facility identified that Resident #49 had allegedly sexually assaulted Resident #62. While the facility was investigating the incident, they implemented one-on-one supervision for both residents. The facility failed to provide one-on-one supervision of Resident #49 for a period of 12 hours. An Immediate Jeopardy situation was identified on 03/19/14. The Immediate Jeopardy was removed on 03/20/14. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 21 residents, 12 of which were women, in the secured unit at risk for serious physical injury and psychological trauma. Findings included: 1.a. Physician orders [REDACTED].#62 was a [AGE] year old female, admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #62 resided on the secured unit. The most recent MDS dated [DATE] indicated Resident #62's cognition was severely impaired. She had unclear speech, disorganized thinking, delusions,with physical and verbal behaviors directed toward others. Resident #62 was ambulatory and had a behavior of wandering daily. Care plans updated 01/15/14 indicated Resident #62 had socially inappropriate behaviors and cognitive deficits. The care plans did not address her wandering behaviors. 1.b. Physician orders [REDACTED].#49 was a [AGE] year old male, admitted on [DATE] with a [DIAGNOSES REDACTED].#49 resided on the secured unit. The most recent MDS dated [DATE] indicted Resident #49's cognition was severely impaired. He had disorganized thinking and delusions. The assessment also indicated he had physical and verbal behaviors directed toward others and wandering. Care plans dated 12/23/13 indicated Resident #49 had impaired thought processes and episodes of confusion. The care plans did not address his physical, verbal, and wandering behaviors. During an interview on 03/19/14 at 12:42 p.m., CNA D said on 03/17/14 just before noon, she went in Resident #62's room to get her up for lunch. She saw scratches and a bruise to her neck and a scratch behind her left ear. She told the charge nurse, LVN H. During an interview on 03/19/14 at 12:55 p.m., LVN H said CNA D called her to Resident #62's room on 03/17/14 about noon to check the bruises on her neck. She said she was training a nurse and had not seen Resident #62 up close until that time. LVN H said she asked the secure unit manager, LVN J, and the LSW to come to the room because of the injuries. LVN H said Resident #62 was fully dressed when she came into the room. LVN H said when she assessed Resident #62, she also had a bruise on her knee. She did a head-to-toe assessment and did not see any bruises or lacerations to her perineal area. An incident report dated 03/17/14 at 12:00 noon for Resident #62 noted, "...Called to residence room by CNA to report abrasions and bruising noted to resident. CNAs were unaware of cause of injuries..." The report noted Resident #62 had the following injuries: abrasion to left chest that measured 4.0 cm x 1.0 cm x 0.5 cm, scratch noted to left cheek, behind left ear lobe, skin raw on left ear lobe, and superficial abrasion to left knee that measured 0.5 cm x 1.0 cm. During an interview on 03/19/14 at 1:00 p.m., CNA F said at approximately 4:00 p.m. on 03/17/14, she checked Resident #62 and she had scratches and bruises on her neck. She said the resident was having difficulty walking and the resident was grabbing her vaginal area. CNA F said she told the charge nurse, LVN K, and the administrator. CNA F said the administrator told her it was being investigated and Resident #62 was being sent to the emergency room . A nursing note for Resident #62 dated 03/17/14 indicated at 5:15 p.m. she was sent to the emergency room for complaint of vaginal pain. An Emergency Physician Record dated 03/17/14 timed 7:18 p.m. noted, "...Patient found in room w/o (without) her underwear on noted abrasion to L (left) side neck and legs. Patient complained of vaginal pain..." There was no documentation under the [MEDICAL CONDITION] examination section. The clinical impression noted, "...Alleged Sexual Assault...multiple abrasions..." The physician ordered Resident #62 be transferred to another hospital for SANE (sexually assaulted nurse examiner) exam. In further interview on 03/19/14 at 1:00 p.m. CNA F said she accompanied Resident #62 to the first emergency room . Resident #62 would not let the physician examine her. CNA F said she told the physician she did not know if Resident #62 was "sexually assaulted or what." Since the resident would not let the physician her, that was why the resident was sent to another hospital for the SANE exam. During an interview on 03/19/14 at 4:58 p.m., the company president said the local police detective contacted him and said the SANE exam indicated Resident #62 had been raped. A nursing note dated 03/18/14 at 4:43 a.m. indicated Resident #62 "...returned to facility with [DIAGNOSES REDACTED]. During an interview on 03/19/14 at 8:00 a.m., the administrator, DON, company president, and consultant identified Resident #49 as the person suspected for sexually assaulting Resident #62. They said Resident #49 and Resident #62 were placed on one on one supervision until Resident #49 could be transferred out of the facility. During an observation and interview on 03/19/14 at 9:00 a.m., Resident #49 was sitting in the dining room area. No staff were sitting with him. CNA A said she did not know if Resident #49 was on one on one supervision. During an interview on 03/19/14 at 9:02 a.m., Activity Director B said she did not know if Resident #49 was on one on one supervision. During an interview on 03/19/14 at 9:06 a.m., LVN C said there were no residents on one on one supervision. LVN C was working the 6:00 a.m.-2:00 p.m. (day) shift. During an interview on 03/19/14 at 9:07 a.m., CNA D said she did not know if Resident #49 was on one on one supervision. CNA D was working the 6:00 a.m.-2:00 p.m. (day) shift. During an interview on 03/19/14 at 10:57 a.m., LVN C said she clocked in at 5:50 a.m. and Resident #49 was in his room with no staff present. Resident #49 was in his room alone until approximately 8:00 a.m. when he came to the dining room for breakfast. An Elopement Risk/Behavior Monitoring Log dated 03/17/14 for Resident #49 indicated at 11:00 p.m. he was placed on monitoring and every fifteen minutes his location was documented. The Elopement Risk/Behavior Monitoring Log noted, "...The resident will continue to be monitored until stated otherwise by the DON or Unit Supervisor..." The last entry made on the monitoring sheet was on 03/18/14 at 9:00 p.m. There was no documentation Resident #49 was supervised after that time. During an interview on 03/19/14 at 9:20 a.m., LVN C acknowledged there was no other one on one sheets for Resident #49 and nothing had been documented since 03/18/14 at 9:00 p.m. LVN C said she was not told in report that Resident #49 was on one on one supervision. During an interview on 03/19/14 at 9:23 a.m., the DON acknowledged there were no other one on one sheets for Resident #49. During an interview on 03/19/14 at 9:18 a.m., CNA E, who worked 10:00 p.m. to 6:00 a.m. on 03/18/14 (night shift), said Resident #49 was "watched closely," but stated, "I can't answer that" about the resident being monitored one on one. CNA E stated, "What do you mean by one on one?" and "Why are you asking me all these questions?" During an interview on 03/19/14 at 9:30 a.m., CNA G said she watched Resident #49 "all the time", but "nobody told me to sign papers." (document on a log). CNA G worked the 10:00 p.m.-6:00 a.m. (night) shift on 03/18/14. The charge nurse for 10:00 p.m. to 6:00 a.m. on 03/18/14 could not be reached by phone. The Abuse Prevention Policy dated December 2013 indicated, "...3. If the alleged abuser is another resident, the two residents shall be separated and the alleged abusive resident shall be temporarily separated from other residents and monitored with one:one supervision as a therapeutic intervention to help lower the agitation, until a plan of care can be developed to meet the needs of the alleged abusive resident." The administrator, DON, company president, and consultant were notified on 03/19/14 at 1:43 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 03/19/14 5:53 p.m. and included: "Plan of Removal regarding IJ (Immediate Jeopardy) of 03/19/14 The following has and is being implemented to protect the residents of (facility name). Please review and inform us if acceptable or if additional action needed. Head-to-toe assessments preformed on all residents on South Wing (Dementia Unit) Secure Head-to-toe assessments preformed on all other residents Interviewed all staff working on South from Sunday 10 - 6 through Monday 2 - 10. Visually inspected nails and arms of all male staff on South Wing for marks Interviewed and checked arms and nails of rest of male staff for same reason Placed (Resident #62) and (Resident #49) on 24 hour observation with q15 minute checks Moved (Resident #62) out of unit keeping both residents apart and observed. Deep cleaned and Revamped (Resident #62's) room for her return Criminal background (public) on (Resident #49) found multiple non-violent arrests. Contracted and gained approval for (Resident #49's) family to take home and seek outpatient mental health care. Moved (Resident #49) to N-Step (another wing) and (Resident #62) back to South Wing(Resident #49) on one-on-one with q15 minute checks until removed from building Started in-services for all staff members on abuse policy, reporting, and monitoring. In-servicing all staff on definition and implementation of 1-on-1 monitoring and q15 minute checks (see attached). Installing closed circuit cameras on South Wing Secure unit (South Wing) door code will be changed monthly" The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Five LVNs were interviewed. All were able to identify and describe the types of abuse, when to report, and how to perform and document one on one resident monitoring. Four CNAs were interviewed. All were able to identify and describe the types of abuse, when to report, and how to perform and document one on one resident monitoring. One MA was interviewed. She was able identify and describe the types of abuse, when to report, and how to perform and document one on one resident monitoring. The one on one monitoring record for Resident #49 dated 03/19/14 beginning at 9:15 a.m. (following surveyor intervention) indicated staff monitored him until 8:15 p.m. until he was taken into custody by the local police department. On 03/20/14 at 10:10 a.m., the administrator, DON, company president, and consultant were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The undated 802 provided 03/20/14 indicated there were 21 residents on the secured unit. Twelve of the 21 residents were women.

Based on observation, interview, and record review, the facility failed to implement their polices and procedures to prevent neglect for 1 of 6 residents reviewed for neglect. (Resident #62) The facility identified that Resident #49 had allegedly sexually assaulted Resident #62. While the facility was investigating the incident, they implemented one-on-one supervision for both residents. The facility failed to provide one-on-one supervision of Resident #49 for a period of 12 hours (from 3/18/14 at 9:00 p.m. - 3/19/14 at 9:00 a.m.). An Immediate Jeopardy situation was identified on 03/19/14. The Immediate Jeopardy was removed on 03/20/14. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 21 residents, 12 of which were women, in the secured unit at risk for serious physical injury and psychological trauma. Findings included: The Abuse Prevention Policy dated December 2013 indicated, "...3. If the alleged abuser is another resident, the two residents shall be separated and the alleged abusive resident shall be temporarily separated from other residents and monitored with one:one supervision as a therapeutic intervention to help lower the agitation, until a plan of care can be developed to meet the needs of the alleged abusive resident." 1.a. Physician orders [REDACTED].#62 was a [AGE] year old female, admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #62 resided on the secured unit. The most recent MDS dated [DATE] indicated Resident #62's cognition was severely impaired. She had unclear speech, disorganized thinking, delusions,with physical and verbal behaviors directed toward others. Resident #62 was ambulatory and had a behavior of wandering daily. Care plans updated 01/15/14 indicated Resident #62 had socially inappropriate behaviors and cognitive deficits. The care plans did not address her wandering behaviors. 1.b. Physician orders [REDACTED].#49 was a [AGE] year old male, admitted on [DATE] with a [DIAGNOSES REDACTED].#49 resided on the secured unit. The most recent MDS dated [DATE] indicted Resident #49's cognition was severely impaired. He had disorganized thinking and delusions. The assessment also indicated he had physical and verbal behaviors directed toward others and wandering. Care plans dated 12/23/13 indicated Resident #49 had impaired thought processes and episodes of confusion. The care plans did not address his physical, verbal, and wandering behaviors. During an interview on 03/19/14 at 12:42 p.m., CNA D said on 03/17/14 just before noon, she went in Resident #62's room to get her up for lunch. She saw scratches and a bruise to her neck and a scratch behind her left ear. She told the charge nurse, LVN H. During an interview on 03/19/14 at 12:55 p.m., LVN H said CNA D called her to Resident #62's room on 03/17/14 about noon to check the bruises on her neck. She said she was training a nurse and had not seen Resident #62 up close until that time. LVN H said she asked the secure unit manager, LVN J, and the LSW to come to the room because of the injuries. LVN H said Resident #62 was fully dressed when she came into the room. LVN H said when she assessed Resident #62, she also had a bruise on her knee. She did a head-to-toe assessment and did not see any bruises or lacerations to her perineal area. An incident report dated 03/17/14 at 12:00 noon for Resident #62 noted, "...Called to residence room by CNA to report abrasions and bruising noted to resident. CNAs were unaware of cause of injuries..." The report noted Resident #62 had the following injuries: abrasion to left chest that measured 4.0 cm x 1.0 cm x 0.5 cm, scratch noted to left cheek, behind left ear lobe, skin raw on left ear lobe, and superficial abrasion to left knee that measured 0.5 cm x 1.0 cm. During an interview on 03/19/14 at 1:00 p.m., CNA F said at approximately 4:00 p.m. on 03/17/14, she checked Resident #62 and she had scratches and bruises on her neck. She said the resident was having difficulty walking and the resident was grabbing her vaginal area. CNA F said she told the charge nurse, LVN K, and the administrator. CNA F said the administrator told her it was being investigated and Resident #62 was being sent to the emergency room . A nursing note for Resident #62 dated 03/17/14 indicated at 5:15 p.m. she was sent to the emergency room for complaint of vaginal pain. An Emergency Physician Record dated 03/17/14 timed 7:18 p.m. noted, "...Patient found in room w/o (without) her underwear on noted abrasion to L (left) side neck and legs. Patient complained of vaginal pain..." There was no documentation under the [MEDICAL CONDITION] examination section. The clinical impression noted, "...Alleged Sexual Assault...multiple abrasions..." The physician ordered Resident #62 be transferred to another hospital for SANE (sexually assaulted nurse examiner) exam. In further interview on 03/19/14 at 1:00 p.m. CNA F said she accompanied Resident #62 to the first emergency room . Resident #62 would not let the physician examine her. CNA F said she told the physician she did not know if Resident #62 was "sexually assaulted or what." Since the resident would not let the physician her, that was why the resident was sent to another hospital for the SANE exam. During an interview on 03/19/14 at 4:58 p.m., the company president said the local police detective contacted him and said the SANE exam indicated Resident #62 had been raped. A nursing note dated 03/18/14 at 4:43 a.m. indicated Resident #62 "...returned to facility with [DIAGNOSES REDACTED]. During an interview on 03/19/14 at 8:00 a.m., the administrator, DON, company president, and consultant identified Resident #49 as the person suspected for sexually assaulting Resident #62. They said Resident #49 and Resident #62 were placed on one on one supervision until Resident #49 could be transferred out of the facility. During an observation and interview on 03/19/14 at 9:00 a.m., Resident #49 was sitting in the dining room area. No staff were sitting with him. CNA A said she did not know if Resident #49 was on one on one supervision. During an interview on 03/19/14 at 9:02 a.m., Activity Director B said she did not know if Resident #49 was on one on one supervision. During an interview on 03/19/14 at 9:06 a.m., LVN C said there were no residents on one on one supervision. LVN C was working the 6:00 a.m.-2:00 p.m. (day) shift. During an interview on 03/19/14 at 9:07 a.m., CNA D said she did not know if Resident #49 was on one on one supervision. CNA D was working the 6:00 a.m.-2:00 p.m. (day) shift. During an interview on 03/19/14 at 10:57 a.m., LVN C said she clocked in at 5:50 a.m. and Resident #49 was in his room with no staff present. Resident #49 was in his room alone until approximately 8:00 a.m. when he came to the dining room for breakfast. An Elopement Risk/Behavior Monitoring Log dated 03/17/14 for Resident #49 indicated at 11:00 p.m. he was placed on monitoring and every fifteen minutes his location was documented. The Elopement Risk/Behavior Monitoring Log noted, "...The resident will continue to be monitored until stated otherwise by the DON or Unit Supervisor..." The last entry made on the monitoring sheet was on 03/18/14 at 9:00 p.m. There was no documentation Resident #49 was supervised after that time. During an interview on 03/19/14 at 9:20 a.m., LVN C acknowledged there was no other one on one sheets for Resident #49 and nothing had been documented since 03/18/14 at 9:00 p.m. LVN C said she was not told in report that Resident #49 was on one on one supervision. During an interview on 03/19/14 at 9:23 a.m., the DON acknowledged there were no other one on one sheets for Resident #49. During an interview on 03/19/14 at 9:18 a.m., CNA E, who worked 10:00 p.m. to 6:00 a.m. on 03/18/14 (night shift), said Resident #49 was "watched closely," but stated, "I can't answer that" about the resident being monitored one on one. CNA E stated, "What do you mean by one on one?" and "Why are you asking me all these questions?" During an interview on 03/19/14 at 9:30 a.m., CNA G said she watched Resident #49 "all the time", but "nobody told me to sign papers." (document on a log). CNA G worked the 10:00 p.m.-6:00 a.m. (night) shift on 03/18/14. The charge nurse for 10:00 p.m. to 6:00 a.m. on 03/18/14 could not be reached by phone. The administrator, DON, company president, and consultant were notified on 03/19/14 at 1:43 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 03/19/14 5:53 p.m. and included: "Plan of Removal regarding IJ (Immediate Jeopardy) of 03/19/14 The following has and is being implemented to protect the residents of (facility name). Please review and inform us if acceptable or if additional action needed. Head-to-toe assessments preformed on all residents on South Wing (Dementia Unit) Secure Head-to-toe assessments preformed on all other residents Interviewed all staff working on South from Sunday 10 - 6 through Monday 2 - 10. Visually inspected nails and arms of all male staff on South Wing for marks Interviewed and checked arms and nails of rest of male staff for same reason Placed (Resident #62) and (Resident #49) on 24 hour observation with q15 minute checks Moved (Resident #62) out of unit keeping both residents apart and observed. Deep cleaned and Revamped (Resident #62's) room for her return Criminal background (public) on (Resident #49) found multiple non-violent arrests. Contracted and gained approval for (Resident #49's) family to take home and seek outpatient mental health care. Moved (Resident #49) to N-Step (another wing) and (Resident #62) back to South Wing(Resident #49) on one-on-one with q15 minute checks until removed from building Started in-services for all staff members on abuse policy, reporting, and monitoring. In-servicing all staff on definition and implementation of 1-on-1 monitoring and q15 minute checks (see attached). Installing closed circuit cameras on South Wing Secure unit (South Wing) door code will be changed monthly" The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Five LVNs were interviewed. All were able to identify and describe the types of abuse, when to report, and how to perform and document one on one resident monitoring. Four CNAs were interviewed. All were able to identify and describe the types of abuse, when to report, and how to perform and document one on one resident monitoring. One MA was interviewed. She was able identify and describe the types of abuse, when to report, and how to perform and document one on one resident monitoring. The one on one monitoring record for Resident #49 dated 03/19/14 beginning at 9:15 a.m. (following surveyor intervention) indicated staff monitored him until 8:15 p.m. until he was taken into custody by the local police department. On 03/20/14 at 10:10 a.m., the administrator, DON, company president, and consultant were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The undated 802 provided 03/20/14 indicated there were 21 residents on the secured unit. Twelve of the 21 residents were women.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision or assistive devices to prevent accidents for 3 of 18 residents reviewed for accidents. (Resident #s 89, 48, and 90) The facility did not develop or make changes to the care plans for the following residents who were at high risk for falls after falls which resulted in injuries: 1. Resident #89 fell from his wheelchair resulting in a compression neck fracture. 2. Resident #48 had an unwitnessed fall and sustained a contusion to the left side of the forehead. 3. Resident #90 sustained a 6 inch bruise to her wrist during a transfer. This failure contributed to the injuries of Resident #s 89, 48, and 90. This failure could place 63 high fall risk residents at risk for injuries. Findings included: 1.Physician orders [REDACTED]. A fall risk care plan initiated on 06/21/12 for Resident #89 noted the following approaches: "Observe resident during rounds on all shifts for changes in status indicating increased fall risk for an actual fall occurrence and assist resident as indicated; Ensure call light is within reach of resident when resident is in room to decrease risks of resident initiating self-transfer without assist; Provide resident education on fall reduction tips and observe resident during rounds on all shifts for compliance; Assist resident with mobility needs as indicated during all shifts to decrease during all shifts to decrease fall risks; and Notify MD and responsible party as indicated for changes identified in resident's fall risk or for an actual fall occurrence." A physician order [REDACTED]. A physician order [REDACTED]. A fall risk assessment for Resident #89 dated 09/07/13 indicated he was high risk for falls. Resident #89's care plans were reviewed on 09/09/12, 12/12/12, 04/24/13, 05/01/13, 06/19/13, and 09/18/13. The care plan included the following changes in the approaches: "Drop seat for w/c (wheelchair); and PT referral (evaluate) and treat as indicated." The care plans did not indicate when the drop seat or PT referral was implemented. The most recent MDS dated [DATE] for Resident #89 indicated severely impaired cognition, extensive assistance needed with transfers, and total dependence of one person for locomotion on/off unit. The assessment indicated he was not steady with balance, but able to stabilize with staff assistance. Incident reports for Resident #89 indicated the following: *02/24/13 - "...Resident found sitting on fall mat at bedside...no injuries noted" *03/05/13- "...Resident found on fall mat...Assessment revealed a reopened wound on R (right) knee. Small amount of blood noted on fall mat and resident from 1 x 1 inch wound. Neuro (sic) started..." *03/11/13- "...Resident's wheelchair alarm went off; aid went to see what was going on. She saw the wheelchair in the hall and him trying to make his way back to it, while trying to get back to the wheelchair, he turned backwards and sat down on the floor...Resident has no injury or bruising noted..." *06/26/13- "...Resident app (sic) leaned forward too far in w/c (wheelchair) and fell on to floor in hallway. Laceration to top of head 2 cm..." *06/27/13- "...CNA was with resident in sunroom cna said she was going to put resident in recliner and turned around to help another resident and this resident attempted to transfer self into recliner in sunroom and slid down on floor in front of recliner...resident assessed for injuries with none found..." *07/09/13- "...At 8:30 p (pm) resident was heard calling help this nurse and CNAs went to check on resident, who was in the floor in sitting position right in front of his wheelchair...stated he had slipped out onto the floor attempting to get into his bed...No injures found." *07/23/13-"...Resident found kneeling at side of bed in another resident's room. Found second toenail on right foot had come off..." *10/12/13-"...Resident was sitting on bedside after being dressed (low bed) and app (sic) slid down onto (sic) floor. Laceration 1.5 cm (centimeter) to left side forehead above eyebrow..." *11/09/13-"...Resident fell forward from w/c (wheelchair), landing prone on floor. Bleeding laceration to bridge of nose. Sent out via 911ambulance. 1/2 in (inch) laceration to bridge of nose..." Resident #89's nursing notes dated 11/09/13 indicated he returned from the emergency room with a compression fracture to C7 (7th cervical (neck) vertebrae). An x-ray report dated 11/09/13 noted, "...acute hairline fracture of the anterior aspect of the C7 vertebral body." The fall risk policy revised December 2007 noted, "...4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the Attending Physician will help the staff reconsider possible causes that may not previously have been identified..." During an interview on 12/04/13/13 at 8:15 a.m., the DON said Resident #89's care plans should be updated with different interventions after each fall. The DON said initially a fall mat, low bed, personal alarm was implemented. The DON said a drop seat was implemented in July 2013. Resident #89's clinical records, including nursing notes dated 02/24/13 to 12/04/13, indicated no other changes were implemented. Physical therapy notes indicated Resident #89 received physical therapy from 01/02/13 to 02/21/13. There was no physical therapy notes indicated Resident #89 was screened for therapy after each fall. A Rehabilitation Screen Form for Resident #89 indicated he was not screened until 10/16/13 and was a poor candidate for therapy due to poor cognition. 2. Physician orders [REDACTED]. His [DIAGNOSES REDACTED]. A care plan dated 08/26/13 indicated to monitor alarms frequently for placement and functioning. Proper footwear or non-skid socks to prevent falls were not on the interdisciplinary care plan. The most recent quarterly MDS dated [DATE] indicated Resident #48 was confused; wheel/chair bound, and needed assistance with all activities of daily living. An incident report dated 10/17/13 at 12:05 a.m. indicated Resident #48 sustained an unwitnessed fall with a head injury. The report indicated he propelled himself to the nursing station the nurse noticed a contusion to the left side of his forehead. The resident reported he fell earlier that night and hit his head on the floor. The intervention was a head to toe assessment with no other injuries noted. No other interventions were initiated. An incident report dated 11/30/13 indicated Resident #48 slid out of his wheelchair. The intervention was to put on shoes to prevent slipping. The undated CNA interdisciplinary care plan-nursing instructions indicated Resident #48 was to have a fall mat and bed and wheelchair alarm for fall precautions. There was no documentation of shoes to prevent slipping or non-slip socks. No other interventions were listed on the CNA care plan. During an observation with the charge Nurse LVN G on 12/02/13 at 9:52 a.m., Resident # 48's room had a low bed, fall mat, and a bed pressure alarm. The pressure alarm was not functioning. During an interview on 12/02/13 at 9:53 a.m., LVN G said the alarm for Resident #48 was not working and she would get a new one. She said they check them, but she had not checked it that day. During an interview on 12/03/13 at 9:15 a.m. the administrator said they reviewed the accident log daily at the stand-up meetings, but do not review the incident report to ensure the report was complete and interventions were implemented. During an interview on 12/03/13 at 9:25 a.m., the unit manager LVN K said when new interventions were initiated after a fall, the MDS coordinator changed the plan of care and updated the CNA care plan or she would tell the charge nurse what to update. During an interview on 12/03/13 at 11:00 a.m., the MDS coordinator LVN I said it was the unit managers' responsibility to update the CNA care plan. During an observation on 12/04/13 at 9:52 a.m., Resident #48 was in the TV room next to the nursing station. He was in a wheelchair with a chair alarm in place. He had on a pair of white socks. They did not have non-skid soles. 3. Physician orders [REDACTED]. A fall risk care plan updated 07/08/13 for Resident #90 noted the following approaches: "Assist resident with all mobility needs as indicated during all shifts; Call light in reach; and Observe on all rounds." The most recent MDS dated [DATE] for Resident #90 indicated moderately impaired cognition, extensive assistance of two persons needed with transfers, and extensive assistance of one person for locomotion on/off unit. A fall risk assessment for Resident #90 dated 10/02/13 indicated she was high risk for falls. An incident report dated 11/04/13 for Resident #90 indicated " ...Large blue/black bruise to right wrist, encircling wrist and 6 inches in width. On questioning regarding how resident obtained the bruise, resident reported it happened during a transfer this morning when going to get her shower...MD contacted; warm compresses applied to wrist area..." During an interview on 12/04/13 at 8:30 a.m., the DON said RN A was responsible for reviewing the incident reports and would have the remaining documentation (witness statements and interventions). During an interview on 12/04/13 at 2:50 p.m., RN B said she filled out the incident report following the incident with Resident #90. She said it occurred on the 6:00 a.m. - 2:00 p.m. shift and she worked the 2:00 p.m. - 10:00 p.m. shift. She said she did not interview any witnesses because they had left for the day. She reported the incident on 11/04/13 to RN A. During an interview on 12/04/13 at 3:15 p.m., unit manager RN A said she was on vacation when the incident occurred and the DON would have been responsible for reviewing incidents. She said CNA C was the aide caring for Resident #90 when the incident occurred. RN A said she was not aware of any interventions or changes to the care plan. During an interview on 12/04/13 at 3:28 p.m., CNA C said she was not Resident # 90's aide and never bathed her. Resident #90's clinical record, including nursing notes dated 11/04/13 to 12/04/13, indicated no changes were implemented following the incident. A list provided on 12/04/13 indicated 63 residents were at high risk for falls.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food under sanitary conditions in 1 of 1 kitchen. 1. The dish room floor had an area containing approximately seven feet by two inches deep of standing waste water with a strong, foul, sewer-type odor permeating the room. Clean dishes were stacked near the waste water pool. Kitchen staff walked through and stood in the waste water while preparing food in the kitchen and serving meals in dining areas. This failure created an Immediate Jeopardy situation. The Immediate Jeopardy was removed on 11/01/12. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete repairs, in-service training, and evaluate the effectiveness of the corrective systems. Non-Immediate Jeopardy 2. In the north wing dining area, dead roaches and mouse droppings were in the credenza drawers where straws, napkins, and utensils were kept. In the N-Step dining area, dead roaches and mouse droppings were at the coffee and sink area and under cabinets. 3. The dish room and food preparation area walls had dust and debris. The light shields in the dish room and food preparation area had a heavy buildup of insects and dust. 4. The dry storage area of the kitchen had mouse droppings around the floor perimeter and around and on the bread crumb bins. 5. The deep fryer had a thick yellow grease build-up on the controls with mouse droppings and live roach activity inside the mechanical controls. This failure could place 87 residents who ate meals prepared in the kitchen at risk for airborne and foodborne illnesses. Findings included: 1. During an observation and interview on 10/29/12 at 10:50 a.m., the dietary manager stepped in a pool of waste water approximately seven feet in diameter and two inches deep with a strong sewer-type odor by the dish machine in the dish room. Her shoes and the hem of her pants were saturated with the water. There was a stack of empty dish racks covering the foul-smelling water. The dietary manager moved the racks to reveal the foul pool of waste water. The clean dishes were stacked near the waste water. A sewer-type odor permeated the dish room. The dietary manager said she reported the standing water to maintenance and the administrator. During an observation on 10/29/12 at 12:15 p.m., the dietary manager was assisting with the lunch service. She walked throughout the kitchen. The hem of her pants was still wet. During interview on 10/30/12 at 9:00 a.m., the maintenance supervisor said he knew the floor was in bad shape and there was standing water. He had tried to repair it, but had been unable to do so. During an observation on 10/30/12 at 9:15 a.m., the dietary manager was standing in a pool of waste water by the dish machine. The water had a strong, foul, sewer-type odor. Her shoes and the cuffs of her pants were wet with the water. During an observation on 10/30/12 at 10:20 a.m., the dietary manager was chopping mushrooms and onions in the food preparation area. The hem of her pants was still wet. During an interview on 10/30/12 at 3:10 p.m., the administrator said the standing water had been a problem for some time, and the smell was bad in that area. He said the entire floor needed to be replaced. During an observation on 10/31/12 at 10:20 a.m., dietary Staff A was standing in a large pool of waste, foul-smelling water in the dishwashing room. Both of his shoes and bottom cuffs of his pants were wet with the waste water. During an observation on 10/31/12 at 10:40 a.m., dietary Staff A was filling water and tea pitchers in both dining rooms. The cuffs of his pants were still wet. During an interview on 10/31/12 at 1:50 p.m., the registered dietitian consultant said she had noted the foul-smelling water in the dish room in her consultant notes several times previously. She said the problem was "horrific" and was a safety issue for the residents. The Consultant Dietitian Report dated 9/12/12 noted: "Sanitary Conditions in Food Preparation Area under Equipment l. Floors and grout (clean / good repair) not met". The administrator and DON were notified on11/01/12 at 9:30 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 11/01/12 at 10:00 a.m. and included: "1. Use disposable dishes and silverware until issue resolved. 2. Repair section of floor where 11 tiles are missing to alleviate any standing water 3. Identify "sewage " smell and address any identified issues with sewer 4. Repair water leak from sink/drain right side of dish machine 5. Plumbers to assess plumbing for necessary repair 6. Rotor out drain" The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: 1. Observation of meal service to ensure disposable dishes and silverware were used. Disposable dishes and utensils were not stored in the dish room. 2. Observations of kitchen dish room floor repair. 3. Observation of plumbing repairs in the kitchen. 4. The dietary manager was interviewed and she was in-servicing staff on procedures for use of disposable dishes and utensils until problem in the kitchen could be resolved. On 11/01/12 at 3:15 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete repairs in the kitchen, complete in-service training, and evaluate the effectiveness of the corrective systems. Non-Immediate Jeopardy 2. Resident Council minutes dated 9/17/12 indicated residents had seen roaches in the kitchen and dining areas. During a group interview on 10/30/12 at 10:00 a.m., 11 of 11 residents complained of roaches in the N-Step dining area. During an observation and interview on 10/31/12 at 2:00 p.m., dead roaches and mouse droppings were in the credenza drawers where utensils, straws, and napkins were kept in the north wing dining area. The DON said housekeeping was supposed to keep those areas clean. During an interview on 10/31/12 at 3:00 p.m., Resident # 65 said she resided on the N-Step unit and ate in the N-Step dining room. She said she attempted to kill a roach by the coffee pot on 10/30/12, but could not catch it. During an observation on 10/31/12 at 3:05 p.m., the sink and coffee pot area in the N-Step dining room had dead roaches. Mouse droppings were under the sink cabinets. 3. During an observation on 10/29/12 at 10:50 a.m., there was dried spattered food and debris on the dish room walls. There was dust on the walls and ceiling in the food preparation area. The light fixtures in the dish room and food preparation areas had a heavy buildup of insects and dust in the light shields. 4. During an observation on 10/29/12 at 11:00 a.m., the dry food storage area had mouse droppings on the floor around the perimeter of the room. There were mouse droppings on and around the bread crumb bins. 5. During an observation on 10/29/12 at 11:05 a.m., the deep fryer had a thick yellow grease build-up on the controls with mouse droppings and live roach activity inside the mechanical controls. During an interview on 10/31/12 at 3:15 p.m., the administrator said he had complaints of pests and he was trying to get a new pest control service to replace the present one. Pest control receipts dated 4/25/12, 7/9/12, 8/22/12, 9/12/12, 9/26/12, 9/28/12, 10/10/12, and 10/24/12 indicated treatments for ants and roaches, but no treatment for [REDACTED]. The Food and Drug Administration Codes 2009, accessed 11/02/12, noted the following: "101.11 surface characteristics. (A) Materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: (1) Smooth, durable, and easily cleanable floor areas where food establishment operations are conducted". A Dietary Services Policy and Procedures Manual dated 1997 indicated " ...it is facility policy to maintain the kitchen in a sanitary state". The CMS 672 dated 10/31/12 indicated 87 residents consumed meals prepared in the kitchen.

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program designed to provide a sanitary environment to prevention the development and transmission of disease and infection for 1 of 1 facility. 1. The dish room floor had an area approximately seven feet by two inches of standing gray water with a strong, foul, sewer-type odor permeating the room. Clean dishes were stacked one shelf away from the foul water pool. Kitchen staff walked through and stood in the foul water while preparing food in the kitchen and serving meals in dining areas. This failure created an Immediate Jeopardy situation. The Immediate Jeopardy was removed on 11/01/12. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete repairs, in-service training, and evaluate the effectiveness of the corrective systems. Non-Immediate Jeopardy 2. In the north wing dining area, dead roaches and mouse droppings were in the credenza drawers where straws, napkins, and utensils were kept. In the N-Step dining area, dead roaches and mouse droppings were at the coffee and sink area and under cabinets. 3. The dish room and food preparation area walls had dust and debris. The light shields in the dish room and food preparation area had a heavy buildup of insects and dust. 4. The dry storage area of the kitchen had mouse droppings around the floor perimeter and around and on the bread crumb bins. 5. The deep fryer had a thick yellow grease build-up on the controls with mouse droppings and live roach activity inside the mechanical controls. This failure could place 87 residents who ate meals prepared in the kitchen at risk for airborne and foodborne illnesses. Findings included: 1. During an observation and interview on 10/29/12 at 10:50 a.m., the dietary manager stepped in a pool of gray water approximately seven feet in diameter and two inches deep with a strong sewer-type odor by the dish machine in the dish room. Her shoes and the hem of her pants were saturated with the water. There was a stack of empty dish racks covering the foul-smelling water. The dietary manager moved the racks to reveal the foul pool of gray water. The clean dishes were stacked one shelf away from the foul pool. A sewer-type odor permeated the dish room. The dietary manager said she reported the standing water to maintenance and the administrator. During an observation on 10/29/12 at 12:15 p.m., the dietary manager was assisting with the lunch service. She walked throughout the kitchen. The hem of her pants was still wet. During interview on 10/30/12 at 9:00 a.m., the maintenance supervisor said he knew the floor was in bad shape and there was standing water. He had tried to repair it, but had been unable to do so. During an observation on 10/30/12 at 9:15 a.m., the dietary manager was standing in a pool of gray water by the dish machine. The water had a strong, foul, sewer-type odor. Her shoes and the cuffs of her pants were wet with the water. During an observation on 10/30/12 at 10:20 a.m., the dietary manager was chopping mushrooms and onions in the food preparation area. The hem of her pants was still wet. During an interview on 10/30/12 at 3:10 p.m., the administrator said the standing water had been a problem for some time, and the smell was bad in that area. He said the entire floor needed to be replaced. During an observation on 10/31/12 at 10:20 a.m., dietary Staff A was standing in a large pool of gray, foul-smelling water in the dishwashing room. Both of his shoes and bottom cuffs of his pants were wet with the foul water. During an observation on 10/31/12 at 10:40 a.m., dietary Staff A was filling water and tea pitchers in both dining rooms. The cuffs of his pants were still wet. During an interview on 10/31/12 at 1:50 p.m., the registered dietitian consultant said she had noted the foul-smelling water in the dish room in her consultant notes several times previously. She said the problem was "horrific" and was a safety issue for the residents. The Consultant Dietitian Report dated 9/12/12 noted: "Sanitary Conditions in Food Preparation Area under Equipment l. Floors and grout (clean / good repair) not met". The administrator and DON were notified on11/01/12 at 9:30 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 11/01/12 at 10:00 a.m. and included: "1. Use disposable dishes and silverware until issue resolved. 2. Repair section of floor where 11 tiles are missing to alleviate any standing water 3. Identify "sewage " smell and address any identified issues with sewer 4. Repair water leak from sink/drain right side of dish machine 5. Plumbers to assess plumbing for necessary repair 6. Rotor out drain" The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: 1. Observation of meal service to ensure disposable dishes and silverware were used. Disposable dishes and utensils were not stored in the dish room. 2. Observations of kitchen dish room floor repair. 3. Observation of plumbing repairs in the kitchen. 4. The dietary manager was interviewed and she was in-servicing staff on procedures for use of disposable dishes and utensils until problem in the kitchen could be resolved. On 11/01/12 at 3:15 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete repairs in the kitchen, complete in-service training, and evaluate the effectiveness of the corrective systems. Non-Immediate Jeopardy 2. Resident Council minutes dated 9/17/12 indicated residents had seen roaches in the kitchen and dining areas. During a group interview on 10/30/12 at 10:00 a.m., 11 of 11 residents complained of roaches in the N-Step dining area. During an observation and interview on 10/31/12 at 2:00 p.m., dead roaches and mouse droppings were in the credenza drawers where utensils, straws, and napkins were kept in the north wing dining area. The DON said housekeeping was supposed to keep those areas clean. During an interview on 10/31/12 at 3:00 p.m., Resident # 65 said she resided on the N-Step unit and ate in the N-Step dining room. She said she attempted to kill a roach by the coffee pot on 10/30/12, but could not catch it. During an observation on 10/31/12 at 3:05 p.m., the sink and coffee pot area in the N-Step dining room had dead roaches. Mouse droppings were under the sink cabinets. 3. During an observation on 10/29/12 at 10:50 a.m., there was dried spattered food and debris on the dish room walls. There was dust on the walls and ceiling in the food preparation area. The light fixtures in the dish room and food preparation areas had a heavy buildup of insects and dust in the light shields. 4. During an observation on 10/29/12 at 11:00 a.m., the dry food storage area had mouse droppings on the floor around the perimeter of the room. There were mouse droppings on and around the bread crumb bins. 5. During an observation on 10/29/12 at 11:05 a.m., the deep fryer had a thick yellow grease build-up on the controls with mouse droppings and live roach activity inside the mechanical controls. During an interview on 10/31/12 at 3:15 p.m., the administrator said he had complaints of pests and he was trying to get a new pest control service to replace the present one. Pest control receipts dated 4/25/12, 7/9/12, 8/22/12, 9/12/12, 9/26/12, 9/28/12, 10/10/12, and 10/24/12 indicated treatments for ants and roaches, but no treatment for [REDACTED]. The Food and Drug Administration Codes 2009, accessed 11/02/12, noted the following: "101.11 surface characteristics. (A) Materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: (1) Smooth, durable, and easily cleanable floor areas where food establishment operations are conducted". A Dietary Services Policy and Procedures Manual dated 1997 indicated " ...it is facility policy to maintain the kitchen in a sanitary state". They CMS 672 dated 10/31/12 indicated 87 residents ate meals prepared in the kitchen.

Based on observation, interview, and record review, the administrator failed to use resources effectively and efficiently to attain or maintain the highest physical, mental, and psychosocial well-being of each resident in 1 of 1 facility. The dish room floor had an area containing approximately seven feet by two inches of standing waste water with a strong, foul, sewer-type odor permeating the room. The administrator said the standing water smelled bad and had been a problem for some time. He offered no interventions that he had implemented to find the source of the waste water or to make repairs. This failure created an Immediate Jeopardy situation. The Immediate Jeopardy was removed on 11/01/12. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 87 residents who ate meals prepared in the kitchen at risk for airborne and foodborne illnesses. Findings included: 1. During an observation and interview on 10/29/12 at 10:50 a.m., the dietary manager stepped in a pool of gray water approximately seven feet in diameter and two inches deep with a strong sewer-type odor by the dish machine in the dish room. Her shoes and the hem of her pants were saturated with the water. There was a stack of empty dish racks covering the foul-smelling water. The dietary manager moved the racks to reveal the foul pool of gray water. The clean dishes were stacked one shelf away from the foul pool. A sewer-type odor permeated the dish room. The dietary manager said she reported the standing water to maintenance and the administrator. During an observation on 10/29/12 at 12:15 p.m., the dietary manager was assisting with the lunch service. She walked throughout the kitchen. The hem of her pants was still wet. During interview on 10/30/12 at 9:00 a.m., the maintenance supervisor said he knew the floor was in bad shape and there was standing water. He had tried to repair it, but had been unable to do so. During an observation on 10/30/12 at 9:15 a.m., the dietary manager was standing in a pool of gray water by the dish machine. The water had a strong, foul, sewer-type odor. Her shoes and the cuffs of her pants were wet with the water. During an observation on 10/30/12 at 10:20 a.m., the dietary manager was chopping mushrooms and onions in the food preparation area. The hem of her pants was still wet. During an interview on 10/30/12 at 3:10 p.m., the administrator said the standing water had been a problem for some time, and the smell was bad in that area. He said the entire floor needed to be replaced. During an observation on 10/31/12 at 10:20 a.m., dietary Staff A was standing in a large pool of gray, foul-smelling water in the dishwashing room. Both of his shoes and bottom cuffs of his pants were wet with the foul water. During an observation on 10/31/12 at 10:40 a.m., dietary Staff A was filling water and tea pitchers in both dining rooms. The cuffs of his pants were still wet. During an interview on 10/31/12 at 1:50 p.m., the registered dietitian consultant said she had noted the foul-smelling water in the dish room in her consultant notes several times previously. She said the problem was "horrific" and was a safety issue for the residents. The Consultant Dietitian Report dated 9/12/12 noted: "Sanitary Conditions in Food Preparation Area under Equipment l. Floors and grout (clean / good repair) not met". The Food and Drug Administration Codes 2009, accessed 11/02/12, noted the following: "101.11 surface characteristics. (A) Materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: (1) Smooth, durable, and easily cleanable floor areas where food establishment operations are conducted". A Dietary Services Policy and Procedures Manual dated 1997 indicated " ...it is facility policy to maintain the kitchen in a sanitary state". The administrator and DON were notified on11/01/12 at 9:30 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 11/01/12 at 10:00 a.m. and included: "1. Use disposable dishes and silverware until issue resolved. 2. Repair section of floor where 11 tiles are missing to alleviate any standing water 3. Identify "sewage" smell and address any identified issues with sewer 4. Repair water leak from sink/drain right side of dish machine 5. Plumbers to assess plumbing for necessary repair 6. Rotor out drain" The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: 1. Observation of meal service to ensure disposable dishes and silverware were used. Disposable dishes and utensils were not stored in the dish room. 2. Observations of kitchen dish room floor repair. 3. Observation of plumbing repairs in the kitchen. 4. The dietary manager was interviewed and she was in-servicing staff on procedures for use of disposable dishes and utensils until problem in the kitchen could be resolved. On 11/01/12 at 3:15 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete repairs in the kitchen, complete in-service training, and evaluate the effectiveness of the corrective systems. They CMS 672 dated 10/31/12 indicated 87 residents ate meals prepared in the kitchen.