Every finding on record at Kent County Nursing Home

Based on observation, interview and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for one of one kitchen reviewing for food and nutrition services. A. Residents #12, #15, and #49 complained the food was served cold. B. 7 of the 9 foods sampled on the meal tray were cold. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and food borne illnesses. The findings included: During an interview on 12/02/2025 at 11:27 AM, Resident #12 stated The food is not good sometimes, I do get cold meals, and it happens most times. The resident stated he ate in the dining and his room sometimes. The resident stated his meals were rarely ever hot or warm enough. During an interview on 12/02/2025 at 11:46 AM, Resident #49 stated The food is off and on, good one day and not the other day, sometimes the food is cold, and it happens always. The resident stated she ate in her room daily. The resident stated her food did not taste good because it was not hot or warm enough. During an interview on 12/02/2025 at 12:12 AM, Resident #15 stated The food is good at times and sometimes not, the food is cold. The resident stated she ate in her room most times. The resident stated this had been an ongoing issue and most meals had been served cold. The resident stated she rarely ever received warm or hot food during meal services. A sample tray was requested on 12/03/2025 at 11:14 AM for all the food forms served and to have the sample trays delivered after the last hall tray were served. During an observation on 12/03/2025 at 12:20 PM, a test tray was provided by [NAME] B, [NAME] C and CNA D. Sample tray findings found by the Surveyor and CNA D were the following: FOOD ITEMS Tempt, TimeRegular Pork (100.28 F)/12:21PMMechanical Pork (105.44 F)/12:21PMPuree Pork (100.96 F)/12:22PMRegular Black-eyed Peas (101.28 F)/12:23PM Puree Black-eyed Peas (100.22 F)/12:23PMRegular Spinach (103.96 F)/12:24PM Puree Spinach (108.68 F)/12:24PM During an interview on 12/04/2025 at 10:13 AM, [NAME] B stated residents never complained that the food was cold, her responsibility was to make sure residents' food was kept and maintained at the right temperature. She stated, Maybe when we take the food out, it stays too long on the cart before the CNA's gets it to the residents. During an interview on 12/04/2025 at 10:29 AM, [NAME] C stated Probably, the cart stays out there too long, occasionally I have seen the cart out there while taking out another one. [NAME] C further stated she reported such to other kitchen staff members, since it was their responsibility to ensure food was served hot. During an interview on 12/04/2025 at 10:39 AM, the DM stated residents never complained that the food was cold. She stated she took temperatures of each food item before it was served to ensure it was at a proper temperature. The DM stated the temperature log was showing lunch was served at proper temperatures. The DM stated she verified the temperatures were adequate right from the steam table. The DM stated this was logged for each meal including at lunch time on 12/03/25. She stated a request of the Food Temperature log was made by the Surveyor. The DM stated she did not know why the test tray contained food that was only slightly warm and/or cold. The DM stated the test tray was served after the last tray was served to the residents. The DM stated she did not know how long it took for nursing staff to distribute residents' room trays. The DM stated if food was not served at a safe temperature, food would no longer be palatable, and residents would get sick. During an interview on 12/04/2025 at 11:09 AM CNA D stated residents did complain about food being cold sometimes. She stated, The food is not warm enough/hot because it takes me long to set up the residents while serving their food and maybe because we do use open carts, I suggest we get the closed ones. CNA D stated if food was not served at a safe temperature, residents would not eat, and eventually they would lose weight. During an interview on 12/04/2025 at 11:42 AM, the ADM stated It is not pleasant, especially if some of the residents like their food warm/hot, if food was not served at a safe temperature obviously one can have a food borne disease. The ADM stated it was his expectation that food trays would be served as soon as they were delivered to each hallway. He stated there must have been a communication breakdown between the kitchen and nursing staff. The ADM stated the DM was responsible for the cooks. Record Review of the facility's document on 12/04/2025 titled, Food Temperature Log dated December 2025, revealed the followings: Lunch: Meat (regular)- 175 degrees; Meat (puree)- 138 degrees; Starch Meat (Mechanical)- 188 degrees; Spinach (regular)- 171 degrees; and Spinach (puree)- 170 degrees. Record Review of the facility's undated policy titled, Food Holding and Service revealed the following: Policy Statement: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be held and served according to the state and US Food Codes and HACCP guidelines. Procedures 1. Serve all hot foods at a temperature of 135 F or greater and all cold food at 41 F or less. Adjust the temperature to account for the time the food will be held prior to service on the steam table and on the tray cart. 4. If hot foods drop below 135 F, reheat to 165 F for a minimum of 15 seconds.

Based observation, interview, and record review, the facility failed to ensure resident had the right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 2 of 4 residents (Resident #3 and #48) observed for physical restraints. Resident #3 and #48 failed to have physician orders for position change alarm (chair alarm) for fall prevention.This failure puts residents at risk of being restrained without justification of the need for a restraint.Findings included:Resident #3 Record review of Resident #3's face sheet, dated 12/3/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (decline in cognitive abilities), muscle weakness, unsteadiness on feet, anxiety (feeling of fear and worry), hypertension (high blood pressure), and major depression disorder (mental health condition that causes a persistently low or depressed mood and loss of interest in activities). Record review of Resident #3's Comprehensive Minimum Data Set, dated [DATE], revealed Resident #3 had a BIMS score of 05 which indicated Resident #3's cognition was severely impaired. Section P revealed no chair alarm in use. Record review of Resident #3's care plan, dated 10/15/2025, revealed a care plan for falls related to weakness, history of falls and dementia. Interventions revealed the resident was able to manipulate the chair/bed pressure alarm physically, turn the alarm off, and the alarm was discontinued. Record review of Resident #3 physician orders dated 12/3/25 revealed no order for position change alarm (chair alarm). During an observation on 12/3/2025 at 03:00 PM Resident #3 was up in wheelchair. Position change alarm (chair alarm) was in place and turned on.During an observation on 12/4/2025 at 09:00 AM Resident #3 was up in wheelchair. Position change alarm (chair alarm) was in place and turned on. Resident #48 Record review of Resident #48's face sheet, dated 12/4/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (decline in cognitive abilities), muscle wasting and atrophy left lower leg (decrease in muscle mass and strength), anxiety (feeling of fear and worry), hypertension (high blood pressure), and major depression disorder (mental health condition that causes a persistently low or depressed mood and loss of interest in activities). Record review of Resident #48's Comprehensive Minimum Data Set, dated [DATE], revealed Resident #48 had a BIMS score of 0 which indicated Resident #48's cognition was severely impaired. Section P revealed no chair alarm in use. Record review of Resident #48's care plan, dated 06/06/2025, revealed a care plan for falls related to confusion. No care plan for position change alarm (chair alarm). Record review of Physician Orders dated 12/4/25 revealed no orders of position change alarm (chair alarm). During an observation on 12/3/2025 at 03:30 PM Resident #48 was up in reclined Geri-chair (medical recliner) with position change alarm in place and turned on.During an observation on 12/4/2025 at 09:00 AM Resident #48 was up in reclined Geri-chair (medical recliner) with position change alarm in place and turned on. During an interview on 12/4/25 at 09:20 AM with the DON, he stated position change alarms were used as an intervention for falls. He stated the position change alarms alerted the staff when the resident changed position. He stated the resident should have had an order for the position change alarm. The DON reviewed Residents #3 and #48 physician orders. He stated Residents #3 and #48 did not have a physician order for the position change alarm.During an interview on 12/4/25 at 11:06 AM with the ADM, he stated position change alarms were used as an intervention for falls. He stated position change alarms should have an order. He stated all staff had received training on the position change alarm policy and procedures. He stated the facility did not have a system to monitor position change alarms, and they needed to develop a system. He stated he did not think position change alarms would be considered a restraint. He stated he was not aware Residents #3 and #48 did not have a physician order for the position change alarm. He stated the potential negative outcome of placing a position change alarm without a physician order could be not following physician orders and the physician not being notified. During an interview on 12/4/25 at 11:29 AM with the DON, he stated they did not have a specific system for monitoring position change alarms. He stated the DON and ADON reviewed physician orders for updates. He stated all staff received training on position change alarm policy and procedures. He stated his expectations were for position change alarms to have a physician order documenting the need. He stated he was not aware Residents #3 and #48 did not have a physician order for the position change alarm. He stated the purpose of a physician order would be to make the physician aware of the position change alarm usage. He stated the potential negative outcome of not having a physician order could be placing a position change alarm without the physician knowledge and the resident or family not being notified. Restraint policy requested from facility on 12/8/25 at 4:26 pm via email. ADM responded on 12/8/25 at 9:27 pm with the following I've attached the only thing I've found pertaining to fall alarms, which is located on the second page & listed as #8 under the Resident-Centered Approaches to Managing Falls and Fall Risk section.Record review of the provided facility policy titled Falls and Fall Risk, Managing with a revised date of March 2018 revealed the following: Policy Statement: Based on previous and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.Resident-Centered Approaches to Managing Falls and Fall Risk.8. Position-change alarms will not be used as the primary or sole intervention to prevent falls but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and maintained in accordance with currently accepted professional standards for 1 of 2 medication carts (Medication Cart 2) reviewed.The facility failed to ensure 11 loose pills in Medication Cart 2 were properly labeled or stored. This failure could place residents at risk for medication errors and drug diversion.The findings include:During an observation of Medication Cart 2 with LVN A and the DON on [DATE] at 10:02AM, 11 loose pills were found in the second drawer. During an interview on [DATE] at 10:21 AM with LVN A, she stated she had been trained to check the medication carts daily for loose pills and weekly for expired items. She stated the person receiving the cart was responsible for making sure the carts were clean and free of loose pills. She stated her last training on the medications carts was in [DATE]. She stated the potential negative outcome could be the residents running out of medication. She stated if she saw a pill in there or dropped a pill into the cart, she would take it out and discard the pill so there would be no risk of giving a resident the wrong medication. She stated nursing staff are expected to check the narcotic counts, keep the carts clean and up to date, and make sure they were stocked.During an interview on [DATE] at 11:13 AM with the DON, he stated he had been able to identify the pills found in Medication Cart 2. He stated the 2 yellow oval pills with H126 printer on the front were Pantoprazole Sodium Delayed- Release 40mg each (medication used to treat and prevent acid reflux). The 3 yellow capsules with 470 printed, were Gabapentin 300mg (medication to treat nerve pain). The 1 large white oval pill was Potassium Chloride 20 meq (supplement to treat low potassium). The small white round pill was metoprolol 25mg (medication used to treat high blood pressure). The 1 small round maroon colored pill was an AZO (over the counter medication used to treat urinary tract burning sensations). The 1 blue capsule was duloxetine delayed release 30mg (medication used to treat depression or anxiety). The 1 pink tablet was levothyroxine 50mcg (medication used to treat low thyroid), and the 1 small round yellow pill was Eliquis 2.5mg (medication used to help prevent blood clots).During an interview with the ADM on [DATE] 09:08 AM, he stated staff were trained to check the carts for cleanliness, narcotic counts and the nurses should be checking the carts together before the off going nurse leaves. He stated if loose pills were in the cart, staff should report it to their DON and destroy the medication in the medication room. He stated a potential negative outcome of loose pills being in the cart could be giving residents the wrong medication, or medication not being properly labeled. During an interview with the DON on [DATE] at 9:46 AM, he stated staff were trained to check the carts for narcotic count, cleanliness, and address any concerns before the off going nurse left. He stated training occurred twice a year and in-services as needed. He stated his expectation of staff was to dispose of any loose pills in the pill destruction box in the medication room after confirming it was not a narcotic. He stated a potential negative outcome of loose pills could be residents running out of medication. He stated if staff dropped a pill into the medication cart, they were not to pull it out and administer it to the resident. He stated any pills that were dropped should be destroyed to prevent any medication errors or giving any wrong medications to any residents.Record review of the facility's policy titled Medication Labeling and Storage last revised 2001, revealed; Medication and biologicals are stored in the packaging, containers or other dispensing systems in which they are received.Medication Labeling: 1. Labeling of medications and biologicals dispensed by the pharmacy is consisted with applicable federal and state requirements and currently accepted pharmaceutical practices. 2. The medications label includes, at a minimum; a. medication name b. prescribed dose. C. strength. Expiration date, when applicable; e. resident's name; f. route of administration and g. appropriate instructions and precautions.

Based on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 2 of 22 residents (Residents #3 and Resident #48) reviewed for care plans. Residents #3 and 48 did not have a care plan for position change alarm (chair alarm). This failure could place residents at risk of not receiving the care required to meet their individual needs. Findings include:Resident #3Record review of Resident #3's face sheet, dated 12/3/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (decline in cognitive abilities), muscle weakness, unsteadiness on feet, anxiety (feeling of fear and worry), hypertension (high blood pressure), and major depression disorder (mental health condition that causes a persistently low or depressed mood and loss of interest in activities). Record review of Resident #3's Comprehensive Minimum Data Set assessment, dated 01/11/25, revealed Resident #3 had a BIMS score of 05 which indicated Resident #3's cognition was severely impaired. Section P revealed no chair alarm in use. Record review of Resident #3's care plan, dated 10/15/2025, revealed a care plan for falls related to weakness, history of falls and dementia. Interventions revealed the resident was able to manipulate the chair/bed pressure alarm physically, turn the alarm off, and the alarm was discontinued. During an observation on 12/3/2025 at 03:00 PM, Resident #3 was up in wheelchair. Position change alarm (chair alarm) was in place and turned on.During an observation on 12/4/2025 at 09:00 AM, Resident #3 was up in wheelchair. Position change alarm (chair alarm) was in place and turned on. Resident #48 Record review of Resident #48's face sheet, dated 12/4/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (decline in cognitive abilities), muscle wasting and atrophy left lower leg (decrease in muscle mass and strength), anxiety (feeling of fear and worry), hypertension (high blood pressure), and major depression disorder (mental health condition that causes a persistently low or depressed mood and loss of interest in activities). Record review of Resident #3's Comprehensive Minimum Data Set, dated [DATE], revealed Resident #48 had a BIMS score of 0 which indicated Resident #48's cognition was severely impaired. Section P revealed no chair alarm in use. Record review of Resident #48's care plan, dated 06/06/2025, revealed a care plan for falls related to confusion. No care plan for position change alarm (chair alarm). During an observation on 12/3/2025 at 03:30 PM, Resident #48 was up in reclined Geri-chair with position change alarm in place and turned on.During an observation on 12/4/2025 at 09:00 AM, Resident #48 was up in reclined Geri-chair with position change alarm in place and turned on. During an interview on 12/4/25 at 09:20 AM with the DON, he stated the position change alarm should be care planned. DON record review Residents #3 and #48 care plans and stated position change alarm had not been care planned.During an interview on 12/4/25 at 11:06 AM with the ADM, he stated the position change alarms was used as an intervention for falls. He stated position change alarms should be care planned. He stated all staff had received training on the position change alarm policy and procedure. He stated the facility did not have a system to monitor position change alarms and they needed to develop a system. He stated he did not think position change alarms would be considered a restraint. He stated he was not aware Residents #3 and #48 did not have a care plan for the position change alarm. He stated the purpose of the care plan was a customized plan of care for each resident. He stated the potential negative outcome of the position change alarm not being care planned could be the resident's interventions not put into place. During an interview on 12/4/25 at 11:29 AM with the DON, he stated the purpose of the care plan was a customized care plan that was individualized needs for the residents. He stated the care plan was used to get to know the residents and what their needs were. He stated the MDS nurse was responsible for care planning. He stated the MDS nurse was off and not in the facility today (12/4/25). He stated they did not have a specific system for monitoring position change alarms. He stated the DON and ADON reviewed care plans for updates. He stated all staff received training on how to use the care plan. He stated his expectations was for all position change alarms to be care planned. He stated he was not aware Residents #3 and #48 did not have a care plan for position change alarm. He stated the potential negative outcome of position change alarms not being care planned could be miscommunication and not providing interventions for the residents. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revised [DATE], reflected:Policy Statement - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Policy Interpretation and Implementation.2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.8. The comprehensive, person-centered care plan will: .b. Describe the services that are to be furnished to attain or maintain the residents' highest practical physical mental and psychosocial well-being.c. Describe services that would otherwise be provided for the above but are not provided due to the resident exercising his or her rights including the right to refuse treatment.g. Incorporate identified problem areas.h. Incorporate risk factors associated with identified problems.j. Reflect the resident's expressed wishes regarding care and treatment goals.k. Reflect treatment goals, timetables and objectives in measurable outcomes; .9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan.10.Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.11.Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.a., when possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers.b. Care planning individual symptoms in isolation may have little, if any, benefit for the resident.13. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.14. The Interdisciplinary Team must review and update the care plan:a. When there has been a significant change in the residents' condition.b. When the desired outcome is not met.c. When the resident has been readmitted to the facility from a hospital stay; andd. At least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interviews and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and neglect for 5 of 7 residents (Resident #1, #2, #3, #4, and #5) reviewed for abuse. A. The Interim DON failed to follow the facility's abuse policy by not reporting the allegation of sexual abuse to HHSC and documenting her investigation measures regarding Resident #1 and Resident #2 reported by Dietary Aide B on an unknown date. B. The Former ADM failed to follow the facility's abuse policy by not reporting the allegation of sexual abuse to HHSC and documenting her investigation measures regarding Resident #1 and Resident #2 reported by Dietary Aide B on an unknown date. C. The Interim DON failed to follow the facility's abuse policy by not reporting the allegation of inappropriate sexual touching to HHSC and documenting her investigation measures regarding Resident #3 and Resident #5 reported by an unknown staff on 03/07/24. D. The Former ADM failed to follow the facility's abuse policy by not reporting the allegation of inappropriate sexual touching to HHSC and documenting her investigation measures regarding Resident #3 and Resident #5 reported by an unknown staff on 03/07/24. E. [NAME] A failed to follow the facility's abuse policy by not reporting the allegation of sexual abuse to the abuse preventionist. F. The DM failed to follow the facility's abuse policy by not reporting the allegation of sexual abuse to the abuse preventionist that involved Resident #1 and Resident #2 that was reported to her by Dietary Aide B on an unknown date. G. LVN F failed to follow the facility's abuse policy by not following up, assessing Resident #4 after CNA E reported that Resident #4 felt uncomfortable around Resident #3 on an unknown date. H. The Former ADM failed to follow the facility's abuse policy by not reporting the allegation of sexual abuse to HHSC and documenting her investigation measures regarding Resident #3 and Resident #5 reported by unknown staff on an unknown date. I. The Former ADM and Interim DON failed to follow the facility's abuse policy by not notifying Family Member G that Resident #4 had expressed she felt uncomfortable around a male resident. An Immediate Jeopardy (IJ) was identified on 11/19/24 at 2:48 PM. The IJ template was provided to the facility on [DATE] at 2.48 PM. While the IJ was removed on 11/20/24 at 1:28 PM, the facility remained out of compliance at a severity level of actual harm and a scope of widespread due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents as risk for abuse and neglect. Findings included: Record review of the facility policy, Abuse Prevention Program, Revised December 2016 revealed: Policy Statement: Our Residents have the right to be free from abuse, neglect .Policy Interpretation and Implementation: As a part of the resident abuse prevention, the administration will: Protect our residents from abuse by anyone including, but not necessarily limited to other residents .Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Identify and assess all possible incidents of abuse; Investigate and report any allegations of abuse within timeframes as required by federal requirements; Protect residents during abuse investigations. Record review of the facility policy, Abuse Investigation and Reporting, revised July 2017 revealed: Policy Statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Policy interpretation: If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. The Administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. Role of the investigator: The individual conducting the investigation will as a minimum; Review the completed documentation forms; Review the resident's medical record; Interview the persons reporting the incident; Interview the resident as medically appropriate; Interview staff members on ALL shifts Interview the resident's roommate; Review all events leading up to the alleged incident; and Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the administrator. Reporting: All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility; The resident's representative (sponsor) of record an alleged violation of abuse, neglect . Two hours if the alleged violation involves abuse . Record review of the facility policy, Recognizing Signs and Symptoms of Abuse/Neglect, Revised April 2021, revealed: Policy Statement: All types of resident abuse, neglect, exploitation, or misappropriation of resident property are strictly prohibited. All personnel are expected to report any signs and symptoms of abuse/neglect to their supervisor or to the director of nursing services immediately. Policy Interpretation: The following are signs and symptoms of abuse/neglect that should be promptly reported. This listing is not all-inclusive. Other signs and symptoms or actual abuse/neglect may be apparent. Psychological or behavioral signs of abuse or neglect: Expression of fear of a person or place, or of being left alone, or of the dark; Paranoia . There were no provider investigation reports available for review from 04/01/24-11/01/24 that involved any of the residents listed in the sample or that pertained to the identified deficient practice. Resident #1 Record Review of Resident #1's face sheet, dated 11/01/24, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss). Record Review of Resident #1's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 14, indicating the resident was not cognitively impaired. Section E did not reveal any documented behaviors for Resident #1. Record Review of Resident #1's Quarterly MDS assessment dated [DATE], revealed Section E did not reveal any documented behaviors for Resident #1. Record review of Resident #1's progress notes dated from 03/02/24- 11/01/24 did not reveal any information regarding the allegation of touching Resident #2's breast or his flirtatious behavior with female residents. Record Review of Resident #1's nursing progress notes entered by the Interim DON dated 05/14/24 at 11:47 PM indicated she spoke with the SW to speak with Resident #1 about calling female staff pet names. A letter was given outlining the facility expectations regarding not calling female staff pet names. Record review of Resident #1's care plan, dated 05/14/24, did not reveal any information regarding his flirtatious behavior towards female residents or allegations regarding touching Resident #2's breast. Resident #2 Record Review of Resident #2's face sheet, dated 11/01/24, revealed a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE], with the following diagnoses: dementia (memory loss) and depression (prolonged period of sadness). Record Review of Resident #2's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 08, indicating the resident was moderately cognitively impaired. Section E did not reveal any documented behaviors for Resident #2. Record Review of Resident #2's Quarterly MDS assessment dated [DATE], revealed Section E did not reveal any documented behaviors for Resident #2. Record review of Resident #2's care plan, dated 08/06/24, did not reveal any information regarding her being touched by another male resident. Further review revealed a focused area, initiated on 08/06/24, that indicated Resident #2 wanted to be in an affectionate relationship with male residents. The goal initiated on 08/06/24 and revised 10/18/24, was based on family wishes for Resident #2 to visit with male resident (unidentified) in the common area. The interventions initiated 08/06/24 included avoid improper touching, avoid going into other residents' room, keeping the family updated with family status, and talking happy about relationships with male residents. Record review of Resident #2's progress notes dated from 03/02/24- 11/01/24 did not reveal any information regarding the allegation of her breast being touched by Resident #1. Record Review of Resident #2's nursing progress notes entered by LVN H dated 08/02/24 at 7:02 PM indicated Resident #2 was in a male (unidentified) room sitting in her wheelchair and a CNA (unidentified) observed the male resident with his pants around his ankles claiming that he was going to have sex with her. During an interview on 11/01/24 at 9:22 AM, [NAME] A stated Resident #1 was a ladies' man. She said he had a history of flirting since his admission. [NAME] A stated there was a history between Resident #1 and #2. She said Resident #1's attempt to flirt and approach Resident #2 caused issues with the other resident, who was no longer at the facility. She said she had not been given any instructions or training regarding Resident #1. She said outside of the incident (Resident #1 touching Resident #2's breast) with Resident #2, she had seen him touch other residents' hands. She said Resident #4 would play with herself. She said she had been told (she could not remember by who) that she would do this when she was nervous. She said this was a known behavior (unable to report for how long) but that male residents would watch her rub on herself in a circular motion. She said staff talked to her about it as much as they could. She said there was an indication that she was about to do it because she would raise her leg. At first, she thought she (resident #4) was itching, but she believed she was checked to rule that out. She said the staff knew to redirect her, offer her a drink, or engage her in another activity. She said she had not received additional training about Resident #4's behavior, but some staff knew how to redirect her. She said if they did not see her raise her legs, it was easy to identify because all the male resident's heads would be turned towards her doing that behavior in the dining room or any common area. She said no other residents have become offended or complained that she was aware of. She said she could not confirm if the other residents were looking at Resident #4 for pleasure or out of shock. During an interview on 11/01/24 at 11:33 AM, CNA E stated over the past month, Resident #4 had a behavior of rubbing herself in her genital area. She said other staff had also noticed it. She said naturally, she and other staff would redirect her. She said they had not received specific training regarding Resident #4 rubbing her genital area. She said they had general knowledge to redirect her since sometimes she would do this in common areas. She said Resident #3 would sit and watch Resident #4 rub herself in her genital area. She said Resident #1 was her (CNA E) family member, and although she had not seen him touch the breasts of anyone, he was known as a big flirt. She said she had observed Resident #1 hold hands with Resident #2 but that Resident #2 was friendly and did not care. She said Resident #2 had a boyfriend who was no longer at the facility, and Resident #1 would stir the pot and upset the resident who was no longer at the facility by flirting with Resident #2. During an interview on 11/01/24 at 9:55 AM, the DM stated Dietary Aide B did report to her that Resident #1 had grabbed Resident #2's breast. She said she was unsure of the exact date. She said she did not witness it, but it was considered inappropriate touching. She said when it was reported to her, she told Dietary Aide B that someone needed to know. She said the ADM was not the administrator and did not know which nurse Dietary Aide B reported the incident to. She said she did not personally report the incident to anyone because she did not personally observe the incident. She said it was her understanding that Dietary Aide B reported the incident to Regional Director J and the charge nurse. She said she could not remember who the charge nurse was. She said she had observed Resident #1 to be social but not overly attentive to any one resident. She said she had not received any special instructions regarding Resident #1. She said although she did not remember the exact date, she did remember the day Dietary Aide B reported the incident. Resident #2 seemed fine and not in any distress. She said she felt if Resident #2 felt threatened, she could tell someone. She said the ADM was the abuse preventionist and had been trained that if she suspected or witnessed abuse, she was to report the allegation to the ADM immediately. She said she had not been interviewed by anyone regarding the incident. During an interview on 11/01/24 at 11:06 AM, the Interim DON stated she no longer worked at the facility. She said she was notified of the incident between Resident #1 and Resident #2. She said she was unsure of the exact date of the incident between Resident #1 and #2, but it was first reported when the Former ADM was employed by Dietary Aide B. She said an investigation was conducted, and it was unfounded by the Former ADM. She said Regional Director J took over after the former ADM left. She said when Regional Director J took over, the incident involving Resident #1 and #2 was brought back up. She said she interviewed Residents (Resident #1 and #2), and nothing was found. She said she was unable to list all she interviewed as she did not work there anymore. She said this may have been in April or May 2024. She said she remembered when she interviewed Resident #1 and Resident #2, both residents denied anything happening and therefore she unfounded the incident. She said there were concerns because each time the new administration would come, the incident of Resident #1 touching Resident #2's breast would come up. She said she did not believe anything had happened because no other allegations had been made since the report. She said it was her understanding that Resident #1 had not approached Resident #2 since the allegation. She said she was unsure why the allegation continued to be addressed, and it seemed to be the kitchen staff that had concerns. She said during her investigation, she found that the people named to be present were not working the day of the incident. The Interim DON said she could not list the people who worked the day of the incident, the date of the incident, and anyone she interviewed, but she unfounded the incident. She said this had been reported to her a total of three times, and she did not report the incident to HHSC during any of those times. She said she did not report the allegation of sexually inappropriate touching because Residents #1 and #2 stated the incident had not occurred, and they unfounded the incident. She said she did keep her eye on Resident #1. She said Family Member G had been notified. She said she had not received any additional reports that Resident #1 had touched any other residents. She said she did not know if she had any written documentation to support her efforts to address the allegations of sexually inappropriate touching from Resident #1. She said she never typed anything up. She said she should have typed something in his progress notes since this was brought up many times. She said she could not pinpoint specific training related to the incident because she had done so many in-services on ANE. She said she did discuss the incident with Regional Director I, and they had decided the incident was not a facility reportable incident because both residents had dementia, and both parties stated nothing happened. She said they agreed that since the kitchen staff kept reporting it, it was retaliation. She said it was not reported to HHSC because there was no proof that it happened and no witnesses. She said that it was known that Dietary Aide B was married into the family of Resident #1 and that she must also protect Resident #1's rights. She said the purpose of following the abuse policy, reporting, and investigating allegations of ANE was to protect the population from ANE, make sure their needs were met, and avoid neglect. She said she had been trained that it was all or none. She said this meant that she was to collect data, have credible witnesses, and then report the incident to HHSC. She said she felt Resident #1 was being painted as a perpetrator based on community rumors. She said she wanted to also protect Resident #1 from false allegations. In regard to documentation, she said she would have to see if she had anything. (The Interim DON did not provide any documentation during the investigation) During an interview on 11/01/24 at 11:33 AM, CNA E stated she said Resident #1 was her (CNA E) family member, and although she had not seen him touch the breasts of anyone, he was known as a big flirt. She said she had observed Resident #1 holding hands with Resident #2 but Resident #2 was friendly and did not care. She said Resident #2 had a boyfriend who was no longer at the facility, and Resident #1 would stir the pot and upset the resident who was no longer at the facility by flirting with Resident #2. During an interview on 11/01/24 at 11:55 AM, RN C stated she was notified a few months ago (unknown exact date and time) by Dietary Aide B that she witnessed Resident #1 touching Resident #2's breast. She said she was told by Dietary Aide B that it did not seem mutual. RN C said she asked Dietary Aide B if she had reported the incident to the Interim DON as they did not have an administrator at the time. She said Dietary Aide B said she had. RN C asked if anything had been done and was told by Dietary Aide B that she did not think anything had been done. RN C stated she encouraged Dietary Aide B to report it again. She said it would have been reported to Regional Director J at this time. She said it was her understanding that it was reported to Regional Director J, who responded that he was aware the incident had been investigated and unfounded. She said she was unaware if it had been reported to HHSC. She said Resident #1 had a history of being friendly with female residents since his admission. She said he would grab the female resident's hands and kiss them. She said she had never seen him grab Resident #2's breast. She said she had not received special instruction regarding Resident #1, nor had she been interviewed regarding the allegation of sexually inappropriate touching between Resident #1 and #2. During an interview on 11/01/24 at 12:01 PM Dietary Aide B stated she was aware of an instance where Resident #1 touched the breast of Resident #2 in the dining room. She said she reported the incident to the Interim DON. She said the incident happened right after Mother's Day in 2024. She said she had seen other inappropriate things from Resident #1. She said she had observed him touch Resident #2's breast more than one time. She said she observed when she opened the door that entered the dining room from the kitchen him touching Resident #2's breast, and when he saw her, he put his hands down, and his face turned red. She said she immediately reported the incident to the Interim DON in the presence of LVN L. She explained to the Interim DON that this was not the first time Resident #1 had been inappropriate with female residents. She said she told the Interim DON that the touching was against Resident #2's will. She said she knew this because Resident #2 did not participate; it was just Resident #1. She said when she reported the incident to the Interim DON, she was told by the Interim DON that she would speak to Resident #2. She said she was also told that because Resident #2 had a boyfriend (no longer at the facility at the time of the investigation), it was ok for Resident #2 to have two boyfriends if she wanted. She said the Interim DON said she would ask Resident #2 if she wanted two boyfriends. She said the Interim DON had also explained to her that the laws had changed. She said she was told that if Resident #2 could not say what happened and if she had memory loss or dementia, there was nothing they could do about it. She said the Interim DON told her to let her know if she saw anything else. She said the former ADM was the administrator at the time of the incident. She said the Interim DON reported the incident to Regional Director J, and he spoke with her about it once. She said Regional Director J asked her what happened, she explained that the incident occurred under the Former ADM and told her to let him know if it happened again. She said it had not happened again, but nothing was done. She said she had not received any special instructions or additional training on what to do regarding Resident #1. She said Regional Director J was the only person who ever asked her anything about the incident. She explained there was another incident involving Resident #1. Still, she did not report it because she was unsure if it was considered inappropriate touching. She said nothing had been done with the incident between Resident #1 and #2. She said she did report the incident between Resident #1 and #2 to the DM but was told for her to report the incident herself. She said her DM told her to report the incident because she did not personally see the incident. She said outside of the interview with the HHSC investigator, she felt the incident had not been thoroughly investigated. During an interview on 11/01/24 at 12:40 PM, Resident #2 stated no one had touched her inappropriately. She said she had a boyfriend but did not remember his name. She said she knew Resident #1, but he had never touched her inappropriately. She said if someone did touch her, she would tell the people at the front. She said no one had asked her any questions before the HHSC investigator about inappropriately being touched. During an interview on 11/01/24 at 1:25 PM, LVN F stated that she knew of the incident between Resident #1 and Resident #2. She stated she was told about the incident by RN C. She said she could not remember the exact date of the incident, but that RN C stated that it was reported to her (RN C) by Dietary Aide B. She (LVN F) stated that she was not questioned or trained in regard to Resident #1 but remembered that the Interim DON said to Dietary Aide B that Resident #2 could have more than one boyfriend if she wanted. She said the incident was also reported to Regional Director J, and it was her understanding that he did an investigation and unsubstantiated the incident, according to RN C. LVN F said Resident #1 had a history of flirting with female residents and holding their hands. She said she had not seen anything to indicate the other female residents were uncomfortable. She said no instructions had been given regarding the behavior of Resident #1 flirting or holding the female resident's hands. She said they told Resident #1 to leave the female residents alone. She said Resident #1 laughed about it. She said it appeared Resident #1 found humor because he reported to them that Resident #2 was his schoolteacher. During an interview on 11/01/24 at 2:39 PM, LVN H stated she said she was unaware of any incidents that involved Resident #1. She said Resident #1 had a history of being with the female residents. She said he liked to sit with them (female residents). During an interview on 11/01/24 at 2:59 PM, Regional Director I stated he did not know anything about a male resident touching the breast of a female resident. He said he could not recall a specific conversation with the Interim DON. He said he had multiple discussions with the Interim DON. He said the Former DON's last day was May 15th or 16th of 2024. He said there were 10 days without an administrator, and then Regional Director J came to run the facility. He said it was his expectation that if staff suspect or witness abuse, they should follow the facility policy. He said it should be reported to HHSC and investigated thoroughly. He said he was unaware of the allegation between Resident #1 and #2. He said the potential negative outcome for the residents would depend on the allegation. During an interview on 11/01/24 at 3:06 PM, Regional Director J stated he was unaware of any incident that occurred between Resident #1 and Resident #2 that involved breast touching. Regional Director J said he was aware that there was a resident who was no longer at the facility and felt that Resident #1 had stolen his woman (Resident #2). He said if there was an allegation of ANE, it should be reported and investigated. He said investigating the incident was important to ensure the resident was safe. He said the investigation process should be documented. During an interview on 11/01/24 at 3:25 PM, Resident #1 stated he had never been questioned about inappropriate behavior or accused of doing anything inappropriate. He stated he did not have a girlfriend but all the ladies at the facility liked him. He said he recently turned [AGE] years old and found out he was a lesbian because he liked girls. He said he does not touch anyone who does not want to be touched. He said he had not touched anyone since he had been at the facility. During an interview on 11/01/24 at 4:43 PM, the DON stated he said he was unaware of any incidents that occurred between Resident #1 and Resident #2. He said he knew Resident #1 would hold people's hands, but it was not specific to female residents. He said he was unaware that Resident #1 would kiss the female residents' hands. During an interview on 11/01/24 at 4:55 PM, the ADM stated he had been trained and was familiar with the facility's ANE policy. He said he was unaware of the incident involving Resident #1 touching Resident #2's breast. He said the potential negative outcome was there could have been the continuation of abuse or whatever was going on. He said not following the abuse policy could place the resident at unnecessary risk. He said the system to monitor abuse was education and communication. He said he had not observed any of the behaviors of the residents discussed. He said he expected the facility abuse policy to be followed. He said it should have been reported to HHSC and investigated. He said everyone was responsible for following the ANE policy, but the administration oversaw the investigation process and reported the allegation to HHSC. He said he did not have a reason why following the facility policy (reporting to HHSC and investigating) was not conducted. He said the investigation process should have been documented if it was conducted. Resident #3 Record Review of Resident #3's face sheet, dated 11/01/24, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss). Record Review of Resident #3's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 15, indicating the resident was not cognitively impaired. Section E did not reveal any documented behaviors for Resident #3. Record Review of Resident #3's Quarterly MDS assessment dated [DATE], revealed Section E did not reveal any documented behaviors for Resident #3. Record Review of Resident #3's nursing progress notes entered by LVN K dated 03/07/24 at 7:04 PM indicated Resident #3 was in the TV room and his pants were unzipped by Resident #5. The CNA (unidentified) hollered out for the residents to stop. Resident #3 did not attempt to stop Resident #5. Record Review of Resident #3's progress notes entered by the SW dated 03/12/24 at 11:36 AM indicated Resident #3 was in the activity room with a female resident unzipping his pants. It was reported that Resident #3 was allowing Resident #5 to unzip his pants. It was reported that Resident #5 had severe dementia and sought out male residents, in particular Resident #3. The SW discussed with Resident #3 about the issue of female resident having dementia and not understanding their actions. The SW informed Resident #3 about notifying staff entering the room and for him to leave the room if it happened again. Record review of Resident #3's care plan, dated 5/03/24, revealed a focused area, initiated on 05/03/24, Resident #3 had been sexually inappropriate allowing a female resident to unzip his pants in a community setting. The goal initiated on 05/03/24, was Resident #3 would have no evidence of sexually inappropriate behavior problems. The interventions included to intervene as necessary to protect the rights and safety of others, discuss the resident's behavior, and monitor behavior episodes. Resident #4 Record Review of Resident #4's face sheet, dated 11/01/24, revealed a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of dementia (memory loss). Record Review of Resident #4's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 10, indicating the resident was moderately cognitively impaired. Section E did not reveal any documented behaviors for Resident #4. Record Review of Resident #4's Quarterly MDS assessment dated [DATE], revealed Section E did not reveal any documented behaviors for Resident #4. Record review of Resident #4's progress notes dated from 03/02/24- 11/01/24 did not reveal any information concerning Resident #3 or the behavior of rubbing herself outside of her clothing. Record review of Resident #4's care plan, dated 09/19/24, did not reveal any information regarding her concerns for Resident #3 or any behaviors of her rubbing herself outside of her clothing near her genital area. During an interview on 11/01/24 at 9:00 AM, the ADM stated he said there had been no issues since he had been at the facility but that he had to educate Resident #3 on not being flirtatious as he had touched another resident's (Resident #4) knee, but nothing out of line. During an interview on 11/01/24 at 11:33 AM, CNA E stated Resident #4 reported to her that she felt uncomfortable with Resident #3. She said other nurses had noticed her discomfort with Resident #3. She said over the past month, Resident #4 had a behavior of rubbing herself in her genital area. She said other staff had also noticed it. She said naturally, she and other staff would redirect her. She said they had not received specific training regarding Resident #4 rubbing her genital area. She said they had general knowledge to redirect her since sometimes she would do this in common areas. She said Resident #3 would sit and watch Resident #4 rub herself in her genital area. She said she was keeping an eye on them both. She said one time (unknown date and time), Resident #4 reported that Resident #3 made her uncomfortable. She said she reported this to LVN F. CNA E said she had observed Resident #3 sitting by Resident #4's door and watching her but Resident #3 would not do it often since Resident #4 had a roommate. During an interview on 11/01/24 at 1:01 PM, Resident #4 stated she felt safe. She said there was a male who made her feel uncomfortable. She [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure the rights of the residents to be free from abuse and neglect for 1 of 7 residents (Resident #2) reviewed for abuse A. The facility failed to keep Resident #2 safe from Resident #1 on an unknown date when Dietary Aide B reported that Resident #1 had touched Resident #2's breast in the dining room on an unknown date to the Interim DON and to Regional Director J on an unknown date multiple times between May 2024-November 2024). An Immediate Jeopardy (IJ) was identified on 11/19/24 at 2:48 PM. The IJ template was provided to the facility on [DATE] at 2:48 PM. While the IJ was removed on 11/20/24 at 1:28 PM, the facility remained out of compliance at a severity level of actual harm and a scope of widespread due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk for serious psychosocial harm from abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Record review of the facility policy, Abuse Prevention Program, Revised December 2016 revealed: Policy Statement: Our Residents have the right to be free from abuse, neglect .Policy Interpretation and Implementation: As a part of the resident abuse prevention, the administration will: Protect our residents from abuse by anyone including, but not necessarily limited to other residents .Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Identify and assess all possible incidents of abuse; Investigate and report any allegations of abuse within timeframes as required by federal requirements; Protect residents during abuse investigations. Record review of the facility policy, Abuse Investigation and Reporting, revised July 2017 revealed: Policy Statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Policy interpretation: If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. The Administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. Role of the investigator: The individual conducting the investigation will as a minimum; Review the completed documentation forms; Review the resident's medical record; Interview the persons reporting the incident; Interview the resident as medically appropriate; Interview staff members on ALL shifts Interview the resident's roommate; Review all events leading up to the alleged incident; and Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the administrator. Reporting: All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility; The resident's representative (sponsor) of record an alleged violation of abuse, neglect . Two hours if the alleged violation involves abuse . Record review of the facility policy, Recognizing Signs and Symptoms of Abuse/Neglect, Revised April 2021, revealed: Policy Statement: All types of resident abuse, neglect, exploitation, or misappropriation of resident property are strictly prohibited. All personnel are expected to report any signs and symptoms of abuse/neglect to their supervisor or to the director of nursing services immediately. Policy Interpretation: The following are signs and symptoms of abuse/neglect that should be promptly reported. This listing is not all-inclusive. Other signs and symptoms or actual abuse/neglect may be apparent. Psychological or behavioral signs of abuse or neglect: Expression of fear of a person or place, or of being left alone, or of the dark; Paranoia . There were no provider investigation reports available for review from 04/01/24-11/01/24 that involved any of the residents listed in the sample or that pertained to the identified deficient practice. Resident #1 Record Review of Resident #1's face sheet, dated 11/01/24, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss). Record Review of Resident #1's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 14, indicating the resident was not cognitively impaired. Section E did not reveal any documented behaviors for Resident #1. Record Review of Resident #1's Quarterly MDS assessment dated [DATE], revealed Section E did not reveal any documented behaviors for Resident #1. Record review of Resident #1's progress notes dated from 03/02/24- 11/01/24 did not reveal any information regarding the allegation of touching Resident #2's breast or his flirtatious behavior with female residents. Record Review of Resident #1's nursing progress notes entered by the Interim DON dated 05/14/24 at 11:47 PM indicated she spoke with the SW to speak with Resident #1 about calling female staff pet names. A letter was given outlining the facility expectations regarding not calling female staff pet names. Record review of Resident #1's care plan, dated 05/14/24, did not reveal any information regarding his flirtatious behavior towards female residents or allegations regarding touching Resident #2's breast. Resident #2 Record Review of Resident #2's face sheet, dated 11/01/24, revealed a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE], with the following diagnoses: dementia (memory loss) and depression (prolonged period of sadness). Record Review of Resident #2's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 08, indicating the resident was moderately cognitively impaired. Section E did not reveal any documented behaviors for Resident #2. Record Review of Resident #2's Quarterly MDS assessment dated [DATE], revealed Section E did not reveal any documented behaviors for Resident #2. Record review of Resident #2's care plan, dated 08/06/24, did not reveal any information regarding her being touched by another male resident. Further review revealed a focused area, initiated on 08/06/24, that indicated Resident #2 wanted to be in an affectionate relationship with male residents. The goal initiated on 08/06/24 and revised 10/18/24, was based on family wishes for Resident #2 to visit with male resident (unidentified) in the common area. The interventions initiated 08/06/24 included avoid improper touching, avoid going into other residents' room, keeping the family updated with family status, and talking happy about relationships with male residents. Record review of Resident #2's progress notes dated from 03/02/24- 11/01/24 did not reveal any information regarding the allegation of her breast being touched by Resident #1. Record Review of Resident #2's nursing progress notes entered by LVN H dated 08/02/24 at 7:02 PM indicated Resident #2 was in a male (unidentified) room sitting in her wheelchair and a CNA (unidentified) observed the male resident with his pants around his ankles claiming that he was going to have sex with her. During an interview on 11/01/24 at 9:22 AM, [NAME] A stated Resident #1 was a ladies' man. She said he had a history of flirting since his admission. [NAME] A stated there was a history between Resident #1 and #2. She said Resident #1's attempt to flirt and approach Resident #2 caused issues with the other resident, who was no longer at the facility. She said she had not been given any instructions or training regarding Resident #1. She said outside of the incident (Resident #1 touching Resident #2's breast) with Resident #2, she had seen him touch other residents' hands. She said Resident #4 would play with herself. She said she had been told (she could not remember by who) that she would do this when she was nervous. She said this was a known behavior (unable to report for how long) but that male residents would watch her rub on herself in a circular motion. She said staff talked to her about it as much as they could. She said there was an indication that she was about to do it because she would raise her leg. At first, she thought she (resident #4) was itching, but she believed she was checked to rule that out. She said the staff knew to redirect her, offer her a drink, or engage her in another activity. She said she had not received additional training about Resident #4's behavior, but some staff knew how to redirect her. She said if they did not see her raise her legs, it was easy to identify because all the male resident's heads would be turned towards her doing that behavior in the dining room or any common area. She said no other residents have become offended or complained that she was aware of. She said she could not confirm if the other residents were looking at Resident #4 for pleasure or out of shock. During an interview on 11/01/24 at 11:33 AM, CNA E stated over the past month, Resident #4 had a behavior of rubbing herself in her genital area. She said other staff had also noticed it. She said naturally, she and other staff would redirect her. She said they had not received specific training regarding Resident #4 rubbing her genital area. She said they had general knowledge to redirect her since sometimes she would do this in common areas. She said Resident #3 would sit and watch Resident #4 rub herself in her genital area. She said Resident #1 was her (CNA E) family member, and although she had not seen him touch the breasts of anyone, he was known as a big flirt. She said she had observed Resident #1 hold hands with Resident #2 but that Resident #2 was friendly and did not care. She said Resident #2 had a boyfriend who was no longer at the facility, and Resident #1 would stir the pot and upset the resident who was no longer at the facility by flirting with Resident #2. During an interview on 11/01/24 at 9:55 AM, the DM stated Dietary Aide B did report to her that Resident #1 had grabbed Resident #2's breast. She said she was unsure of the exact date. She said she did not witness it, but it was considered inappropriate touching. She said when it was reported to her, she told Dietary Aide B that someone needed to know. She said the ADM was not the administrator and did not know which nurse Dietary Aide B reported the incident to. She said she did not personally report the incident to anyone because she did not personally observe the incident. She said it was her understanding that Dietary Aide B reported the incident to Regional Director J and the charge nurse. She said she could not remember who the charge nurse was. She said she had observed Resident #1 to be social but not overly attentive to any one resident. She said she had not received any special instructions regarding Resident #1. She said although she did not remember the exact date, she did remember the day Dietary Aide B reported the incident. Resident #2 seemed fine and not in any distress. She said she felt if Resident #2 felt threatened, she could tell someone. She said the ADM was the abuse preventionist and had been trained that if she suspected or witnessed abuse, she was to report the allegation to the ADM immediately. She said she had not been interviewed by anyone regarding the incident. During an interview on 11/01/24 at 11:06 AM, the Interim DON stated she no longer worked at the facility. She said she was notified of the incident between Resident #1 and Resident #2. She said she was unsure of the exact date of the incident between Resident #1 and #2, but it was first reported when the Former ADM was employed by Dietary Aide B. She said an investigation was conducted, and it was unfounded by the Former ADM. She said Regional Director J took over after the former ADM left. She said when Regional Director J took over, the incident involving Resident #1 and #2 was brought back up. She said she interviewed Residents (Resident #1 and #2), and nothing was found. She said she was unable to list all she interviewed as she did not work there anymore . She said this may have been in April or May 2024. She said she remembered when she interviewed Resident #1 and Resident #2, both residents denied anything happening and therefore she unfounded the incident. She said there were concerns because each time the new administration would come, the incident of Resident #1 touching Resident #2's breast would come up. She said she did not believe anything had happened because no other allegations had been made since the report. She said it was her understanding that Resident #1 had not approached Resident #2 since the allegation. She said she was unsure why the allegation continued to be addressed, and it seemed to be the kitchen staff that had concerns. She said during her investigation, she found that the people named to be present were not working the day of the incident. The Interim DON said she could not list the people who worked the day of the incident, the date of the incident, and anyone she interviewed, but she unfounded the incident . She said this had been reported to her a total of three times, and she did not report the incident to HHSC during any of those times. She said she did not report the allegation of sexually inappropriate touching because Residents #1 and #2 stated the incident had not occurred, and they unfounded the incident. She said she did keep her eye on Resident #1. She said Family Member G had been notified. She said she had not received any additional reports that Resident #1 had touched any other residents. She said she did not know if she had any written documentation to support her efforts to address the allegations of sexually inappropriate touching from Resident #1. She said she never typed anything up. She said she should have typed something in his progress notes since this was brought up many times. She said she could not pinpoint specific training related to the incident because she had done so many in-services on ANE. She said she did discuss the incident with Regional Director I, and they had decided the incident was not a facility reportable incident because both residents had dementia, and both parties stated nothing happened. She said they agreed that since the kitchen staff kept reporting it, it was retaliation. She said it was not reported to HHSC because there was no proof that it happened and no witnesses. She said that it was known that Dietary Aide B was married into the family of Resident #1 and that she must also protect Resident #1's rights. She said the purpose of following the abuse policy, reporting, and investigating allegations of ANE was to protect the population from ANE, make sure their needs were met, and avoid neglect. She said she had been trained that it was all or none. She said this meant that she was to collect data, have credible witnesses, and then report the incident to HHSC. She said she felt Resident #1 was being painted as a perpetrator based on community rumors. She said she wanted to also protect Resident #1 from false allegations. In regard to documentation, she said she would have to see if she had anything. (The Interim DON did not provide any documentation during the investigation) During an interview on 11/01/24 at 11:33 AM, CNA E stated she said Resident #1 was her (CNA E) family member, and although she had not seen him touch the breasts of anyone, he was known as a big flirt. She said she had observed Resident #1 holding hands with Resident #2 but Resident #2 was friendly and did not care. She said Resident #2 had a boyfriend who was no longer at the facility, and Resident #1 would stir the pot and upset the resident who was no longer at the facility by flirting with Resident #2. During an interview on 11/01/24 at 11:55 AM, RN C stated she was notified a few months ago (unknown exact date and time) by Dietary Aide B that she witnessed Resident #1 touching Resident #2's breast. She said she was told by Dietary Aide B that it did not seem mutual. RN C said she asked Dietary Aide B if she had reported the incident to the Interim DON as they did not have an administrator at the time. She said Dietary Aide B said she had. RN C asked if anything had been done and was told by Dietary Aide B that she did not think anything had been done. RN C stated she encouraged Dietary Aide B to report it again. She said it would have been reported to Regional Director J at this time. She said it was her understanding that it was reported to Regional Director J, who responded that he was aware the incident had been investigated and unfounded. She said she was unaware if it had been reported to HHSC. She said Resident #1 had a history of being friendly with female residents since his admission. She said he would grab the female resident's hands and kiss them. She said she had never seen him grab Resident #2's breast. She said she had not received special instruction regarding Resident #1, nor had she been interviewed regarding the allegation of sexually inappropriate touching between Resident #1 and #2. During an interview on 11/01/24 at 12:01 PM Dietary Aide B stated she was aware of an instance where Resident #1 touched the breast of Resident #2 in the dining room. She said she reported the incident to the Interim DON. She said the incident happened right after Mother's Day in 2024. She said she had seen other inappropriate things from Resident #1. She said she had observed him touch Resident #2's breast more than one time. She said she observed when she opened the door that entered the dining room from the kitchen him touching Resident #2's breast, and when he saw her, he put his hands down, and his face turned red. She said she immediately reported the incident to the Interim DON in the presence of LVN L. She explained to the Interim DON that this was not the first time Resident #1 had been inappropriate with female residents. She said she told the Interim DON that the touching was against Resident #2's will. She said she knew this because Resident #2 did not participate; it was just Resident #1. She said when she reported the incident to the Interim DON, she was told by the Interim DON that she would speak to Resident #2. She said she was also told that because Resident #2 had a boyfriend (no longer at the facility at the time of the investigation), it was ok for Resident #2 to have two boyfriends if she wanted. She said the Interim DON said she would ask Resident #2 if she wanted two boyfriends. She said the Interim DON had also explained to her that the laws had changed. She said she was told that if Resident #2 could not say what happened and if she had memory loss or dementia, there was nothing they could do about it. She said the Interim DON told her to let her know if she saw anything else. She said the former ADM was the administrator at the time of the incident. She said the Interim DON reported the incident to Regional Director J, and he spoke with her about it once. She said Regional Director J asked her what happened, she explained that the incident occurred under the Former ADM and told her to let him know if it happened again. She said it had not happened again, but nothing was done. She said she had not received any special instructions or additional training on what to do regarding Resident #1. She said Regional Director J was the only person who ever asked her anything about the incident. She explained there was another incident involving Resident #1. Still, she did not report it because she was unsure if it was considered inappropriate touching. She said nothing had been done with the incident between Resident #1 and #2. She said she did report the incident between Resident #1 and #2 to the DM but was told for her to report the incident herself. She said her DM told her to report the incident because she did not personally see the incident. She said outside of the interview with the HHSC investigator, she felt the incident had not been thoroughly investigated. During an interview on 11/01/24 at 12:40 PM, Resident #2 stated no one had touched her inappropriately. She said she had a boyfriend but did not remember his name. She said she knew Resident #1, but he had never touched her inappropriately. She said if someone did touch her, she would tell the people at the front. She said no one had asked her any questions before the HHSC investigator about inappropriately being touched. During an interview on 11/01/24 at 1:25 PM, LVN F stated that she knew of the incident between Resident #1 and Resident #2. She stated she was told about the incident by RN C. She said she could not remember the exact date of the incident, but that RN C stated that it was reported to her (RN C) by Dietary Aide B. She (LVN F) stated that she was not questioned or trained in regard to Resident #1 but remembered that the Interim DON said to Dietary Aide B that Resident #2 could have more than one boyfriend if she wanted. She said the incident was also reported to Regional Director J, and it was her understanding that he did an investigation and unsubstantiated the incident, according to RN C. LVN F said Resident #1 had a history of flirting with female residents and holding their hands. She said she had not seen anything to indicate the other female residents were uncomfortable. She said no instructions had been given regarding the behavior of Resident #1 flirting or holding the female resident's hands. She said they told Resident #1 to leave the female residents alone. She said Resident #1 laughed about it. She said it appeared Resident #1 found humor because he reported to them that Resident #2 was his schoolteacher. During an interview on 11/01/24 at 2:39 PM, LVN H stated she said she was unaware of any incidents that involved Resident #1. She said Resident #1 had a history of being with the female residents. She said he liked to sit with them (female residents ). During an interview on 11/01/24 at 2:59 PM, Regional Director I stated he did not know anything about a male resident touching the breast of a female resident. He said he could not recall a specific conversation with the Interim DON. He said he had multiple discussions with the Interim DON. He said the Former DON's last day was May 15th or 16th of 2024. He said there were 10 days without an administrator, and then Regional Director J came to run the facility. He said it was his expectation that if staff suspect or witness abuse, they should follow the facility policy. He said it should be reported to HHSC and investigated thoroughly. He said he was unaware of the allegation between Resident #1 and #2. He said the potential negative outcome for the residents would depend on the allegation. During an interview on 11/01/24 at 3:06 PM, Regional Director J stated he was unaware of any incident that occurred between Resident #1 and Resident #2 that involved breast touching. Regional Director J said he was aware that there was a resident who was no longer at the facility and felt that Resident #1 had stolen his woman (Resident #2). He said if there was an allegation of ANE, it should be reported and investigated. He said investigating the incident was important to ensure the resident was safe. He said the investigation process should be documented. During an interview on 11/01/24 at 3:25 PM, Resident #1 stated he had never been questioned about inappropriate behavior or accused of doing anything inappropriate. He stated he did not have a girlfriend but all the ladies at the facility liked him. He said he recently turned [AGE] years old and found out he was a lesbian because he liked girls. He said he does not touch anyone who does not want to be touched. He said he had not touched anyone since he had been at the facility. During an interview on 11/01/24 at 4:43 PM, the DON stated he said he was unaware of any incidents that occurred between Resident #1 and Resident #2. He said he knew Resident #1 would hold people's hands, but it was not specific to female residents. He said he was unaware that Resident #1 would kiss the female residents' hands. During an interview on 11/01/24 at 4:55 PM, the ADM stated he had been trained and was familiar with the facility's ANE policy. He said he was unaware of the incident involving Resident #1 touching Resident #2's breast. He said the potential negative outcome was there could have been the continuation of abuse or whatever was going on. He said not following the abuse policy could place the resident at unnecessary risk. He said the system to monitor abuse was education and communication. He said he had not observed any of the behaviors of the residents discussed. He said he expected the facility abuse policy to be followed. He said it should have been reported to HHSC and investigated. He said everyone was responsible for following the ANE policy, but the administration oversaw the investigation process and reported the allegation to HHSC. He said he did not have a reason why following the facility policy (reporting to HHSC and investigating) was not conducted. He said the investigation process should have been documented if it was conducted . HHSC Investigator re-entered the facility on 11/19/24 at 8:45 AM to gather additional information at the request of Region 1. The ADM, the DON, the ADON, Regional Director J, and the Regional Nursing Consultant were notified on 11/19/24 at 2:48 PM and IJ situation was identified due to the above failures and the IJ template was provided. The following Plan of Removal submitted by the facility was accepted on 11/20/24 at 8:31 AM: Plan of Removal: 607: Investigate/Prevent/Correct Alleged Violations F607 Based on interviews and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and neglect for 2 of 6 residents (Resident #1 and #2) reviewed for abuse. 1. Immediate Actions Taken for Those Residents Identified: Action: Residents #1, and #2 received a head-to-toe assessment and an emotional assessment. Person(s) Responsible: Charge Nurse & Social Worker and/or Designee Date: 11/19/2024 Action: Resident #1 was placed on 1:1 for 72-hours from 11/1-11/4. Resident #1 was no longer deemed a risk to others. Person(s) Responsible: Administrator, Director of Nursing, and/or Designee Date: 11/4/2024 2. How the Facility Identified Other Possibly Affected Residents: Action: Resident safe surveys completed to establish affected residents. Any other concerns noted will received a head-to-toe assessment and an emotional assessment. Person(s) Responsible: Administrator, Social Worker, and/or Designee Date: 11/19/2024 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Education provided to Administrator and Regional Director by Regional Nurse Consultant. Further, all available facility staff were in-serviced by the Administrator starting immediately after IJ was called. All identified staff that continues to work for the nursing facility by Administrator will be in-serviced over the abuse policy and investigating and reporting abuse per HHS and CMS regulations. Person(s) Responsible: RNC, Administrator or designee Date: 11/19/2024 Action: All staff educated on immediately intervening to protect residents in the event of abuse, reporting to the abuse coordinator, assessing the resident, and following up with the abuse coordinator. All staff will be educated prior to working their next shift. Person(s) Responsible: Administrator, Director of Nursing, and/or Designee Date: 11/19/2024 4. How the Corrective Actions Will be Monitored, by whom and for how long: Action: 5 staff and 5 residents will be interviewed weekly to ensure any allegations of abuse have been reported to the administrator per the regulation x4 weeks. Any allegations made during the interview will be reported immediately. Staff noted not following policy will be reeducated on the facility's abuse policy. Person(s) Responsible: Administrator and/or Designee Date: 11/20/2024 QAPI- Action: Medical Director notified of the Immediate Jeopardy template and the facility's plan to remove it. No additional recommendations at this time. Person(s) Responsible: Administrator Date: 11/19/2024 On 11/20/24 at 11:23 AM the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of the facility provider investigation report, dated 11/09/24, revealed the following: A written statement signed 11/09/24 by the Interim DON said that Dietary Aide B came to her office (date not disclosed) and reported that she witnessed Resident #1 touch Resident #2 on breast in the dining room. She (the Interim DON) reported the incident to the Former ADM, but she (the Former DON) did nothing. She said some of the witnesses that Dietary Aide B reported saw the incident did not work on the day Dietary Aide B stated the incident happened. (The written statement did not contain the witnesses' or the alleged incident date). The Interim DON wrote that she spoke with Resident #1, who denied sexual contact with Resident #2, but Resident #1 did admit to holding Resident #2's hands. The Interim DON wrote in her statement that Resident #1 had no allegations of sexual contact with any resident or staff at the facility. The Interim DON wrote that Resident #2 denied anyone had touched her anywhere on her body and that she (Resident #2) felt safe. She wrote that Resident #2 confirmed that she held hands with Resident #1. She wrote that she notified Resident #2's POA. She said Dietary Aide B voiced the allegations to Resident #1, two Administrators, and the Interim DON. (The written statement did not include the names of the two administrators. A letter dated 4/4/24, signed/acknowledged by Resident #1, addressed him using pet names such as baby and honey, which made the staff feel uncomfortable. Record review of a facility in-service, ANE, and resident Rights, dated 11/02/24, revealed the following:28 Staff were in-serviced on the following: Every individual was responsible for identifying abuse, neglect, exploitation, and misappropriation in the facility and reporting any allegation or suspicion of these events to the abuse coordinator. It stated that in the event that the abuse coordinator was unavailable, the alternate abuse coordinator was the DON. Record review of facility in-service, ANE, and Reporting, dated 10/17/24, revealed the following: Regional Director J in-serviced the ADM, the DON, the ADON, and LVN K on Long-Term Care Regulation Provider 2024-14, dated 08/29/24, which discussed Reportable incidents and Timeframes. Record review of facility in-service, Event Reporting, dated 11/19/24, revealed the following: The ADM, the DON, and Regional Director J were in-serviced on event reporting. The in-service discussed key aspects (confidentiality, analysis, feedback/learning, and regulatory compliance) of event reporting. The in-service also included the required parties to be notified: the resident responsible party, emergency contact, the DON, the administration, and the abuse preventionist. Record review of facility in-service, Event Reporting, dated 11/19/24, revealed the following: The regional nursing consultant serviced [TRUNCATED]

Based on interviews and record review the facility failed to ensure allegations of abuse, neglect, exploitation, or mistreatment have evidence that all alleged violations were thoroughly investigated and prevented further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress and reported the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation was verified appropriate corrective action were taken, for 5 of 7 residents (Resident #1, #2, #3, #4, and #5) reviewed for abuse. A. The Interim DON failed to follow the facility's abuse policy by not documenting her investigation measures and implementing protective measures regarding Resident #1 and Resident #2 involvement in inappropriate sexual touching reported by Dietary Aide B on an unknown date. B. The Former ADM failed to follow the facility's abuse policy by not documenting her investigation measures and implementing protective measures regarding Resident #1 and Resident #2 involvement in inappropriate sexual touching reported by Dietary Aide B on an unknown date. C. The Interim DON failed to follow the facility's abuse policy by not documenting her investigation measures and implementing protective measures regarding Resident #3 and Resident #5 involvement of inappropriate touching reported by an unknown staff on 03/07/24. D. The Former ADM failed to follow the facility's abuse policy by not documenting her investigation measures and implementing protective measures regarding Resident #3 and Resident #5 involvement of inappropriate touching reported by an unknown staff on 03/07/24. E. The Interim DON, LVN F, and CNA E failed to follow the facility's abuse policy by not documenting her investigation measures and implementing protective measures regarding Resident #3 and Resident #4 after Resident #4 expressed that she felt unsafe around Resident #3. An Immediate Jeopardy (IJ) was identified on 11/19/24 at 2:48 PM. The IJ template was provided to the facility on [DATE] at 2:48 PM. While the IJ was removed on 11/20/24 at 1:28 PM, the facility remained out of compliance at a severity level of actual harm and a scope of widespread due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents as risk for abuse and neglect by not investigating and implementing preventative measures in place. Findings included: Resident #1 Record Review of Resident #1's face sheet, dated 11/01/24, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss). Record Review of Resident #1's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 14, indicating the resident was not cognitively impaired. Section E did not reveal any documented behaviors for Resident #1. Record Review of Resident #1's Quarterly MDS assessment dated [DATE], revealed under Section E did not reveal any documented behaviors for Resident #1. Record review of Resident #1's progress notes dated from 03/02/24- 11/01/24 did not reveal any information regarding the allegation of touching Resident #2 breast or his flirtatious behavior with female residents. Record Review of Resident #1's nursing progress notes entered by the Interim DON dated 05/14/24 at 11:47 PM indicated she spoke with the SW to speak with Resident #1 about calling female staff pet names. A letter was given outlining the facility expectations regarding not calling female staff pet names. Record review of Resident #1's care plan, dated 05/14/24, did not reveal any information regarding his flirtatious behavior towards female residents or allegation regarding touching Resident #2's breast. Resident #2 Record Review of Resident #2's face sheet, dated 11/01/24, revealed a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE], with the following diagnoses: dementia (memory loss), and depression (prolonged period of sadness). Record Review of Resident #2's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 08, indicating the resident was moderately cognitively impaired. Section E did not reveal any documented behaviors for Resident #2. Record Review of Resident #2's Quarterly MDS assessment dated [DATE], revealed under Section E did not reveal any documented behaviors for Resident #2. Record review of Resident #2's care plan, dated 08/06/24, did not reveal any information regarding her being touched by another male resident .Further review revealed a focused area, initiated on 08/06/24, that indicated Resident #2 wanted to be in an affectionate relationship with male residents. The goal initiated on 08/06/24 revised 10/18/24, was based on family wishes for Resident #2 to visit with male resident (unidentified) in the common area. The interventions initiated 08/06/24 included avoid improper touching, avoid going into other residents room, keeping resident family updated with relationship status and talking often about being happy when she is in a relationship with male residents. Record review of Resident #2's progress notes dated from 03/02/24- 11/01/24 did not reveal any information regarding the allegation of her breast being touched by Resident #1. Record Review of Resident #2's nursing progress notes entered by LVN H dated 08/02/24 at 7:02 PM indicated Resident #2 was in a male (unidentified) room sitting in her wheelchair and a CNA (unidentified) observed the male resident with his pants around his ankles claiming that he was going to have sex with her. During an interview on 11/01/24 at 9:55 AM, the DM stated Dietary Aide B did report to her that Resident #1 had grabbed Resident #2's breast. She said she was unsure of the exact date. She said she did not witness it but considered inappropriate touching. She said when it was reported to her, she told Dietary Aide B that someone needed to know. She said the ADM was not the administrator and did not know which nurse Dietary Aide B reported the incident to. She said she did not personally report the incident to anyone because she did not personally observe the incident. She said it was her understanding that Dietary Aide B reported the incident to Regional Director J and the charge nurse. She said she could not remember who the charge nurse was. She said she had observed Resident #1 to be social but not overly attentive to any one resident. She said she had not received any special instructions regarding Resident #1. She said although she did not remember the exact date, she did remember the day Dietary Aide B reported the incident. Resident #2 seemed fine and not in any distress. She said she felt if Resident #2 felt threatened, she could tell someone. She said the ADM was the abuse preventionist and had been trained that if she suspected or witnessed abuse, she was to report the allegation to the ADM immediately. She said she had not been interviewed by anyone regarding the incident. During an interview on 11/01/24 at 11:06 AM, the Interim DON stated she no longer worked at the facility. She said she was notified of the incident between Resident #1 and Resident #2. She said she was unsure of the exact date of the incident between Resident #1 and #2, but it was first reported when the Former ADM was employed by dietary Aide B. She said an investigation was conducted, and it was unfounded by the Former ADM. She said Regional Director J took over after the former ADM left. She said when Regional Director J took over, the incident involving Resident #1 and #2 was brought back up. She said she interviewed Residents (Resident #1 and #2), and nothing was found. She said she was unable to list all she interviewed as she did not work there anymore. She said this may have been in April or May 2024. She said she remembered when she interviewed Resident #1 and Resident #2, both residents denied anything happening and therefore unfounded the incident. She said there were concerns because each time the new administration would come, the incident of Resident #1 touching Resident #2's breast would come up. She said she did not believe anything had happened because no other allegations had been made since the report. She said it was her understanding that Resident #1 had not approached Resident #2 since the allegation. She said she was unsure why the allegation continues to be addressed, and it seemed to be the kitchen staff that had concerns. She said during her investigation, she found that the people named to be present were not working the day of the incident. The Interim DON said she could not list the people who worked the day of the incident, the date of the incident, and anyone she interviewed, but she unfounded the incident. She said this had been reported to her a total of three times, and she did not report the incident to HHSC during any of those times. She said she did not report the allegation of sexually inappropriate touching because Residents #1 and #2 stated the incident had not occurred, and they unfounded the incident. She said she did keep her eye on Resident #1. She said Family Member G had been notified. She said she had not received any additional reports that Resident #1 had touched any other residents. She said she did not know if she had any written documentation to support her efforts to address the allegations of sexually inappropriate touching from Resident #1. She said she never typed anything up. She said she should have typed something in his progress notes since this was brought up many times. She said she could not pinpoint specific training related to the incident because she had done so many in-services on ANE. She said she did discuss the incident with Regional Director I, and they had decided the incident was not a facility reportable incident because both residents had dementia, and both parties stated nothing happened. She said they agreed that since the kitchen staff kept reporting it, it was retaliation. She said it was not reported to HHSC because there was no proof that it happened and no witnesses. She said that it was known that Dietary Aide B was married into the family of Resident #1 and that she must also protect Resident #1's rights. She said the purpose of following the abuse policy, reporting, and investigating allegations of ANE was to protect the population from ANE, make sure their needs were met, and avoid neglect. She said she had been trained that it was all or none. She said this meant that she was to collect data, have credible witnesses, and then report the incident to HHSC. She said she felt Resident #1 was being painted as a perpetrator based on community rumors. She said she wanted to also protect Resident #1 from false allegations. In regard to documentation, she said she would have to see if she had anything. (The Interim DON did not provide any documentation during the investigation) During an interview on 11/01/24 at 11:33 AM, CNA E stated she said Resident #1 was her (CNA E) family member, and although she had not seen him touch the breasts of anyone, he was known as a big flirt. She said she had observed Resident #1 hold hands with Resident #2 but Resident #2 was friendly and did not care. She said Resident #2 had a boyfriend who was no longer at the facility, and Resident #1 would stir the pot and upset the resident who was no longer at the facility by flirting with Resident #2. During an interview on 11/01/24 at 11:55 AM, RN C stated she was notified a few months ago (unknown exact date and time) by Dietary Aide B that she witnessed Resident #1 touching Resident #2's breast. She said she was told by Dietary Aide B that it did not seem mutual. RN C said she asked Dietary Aide B if she had reported the incident to the Interim DON as they did not have an administrator at the time. She said Dietary Aide B said she had. RN C asked if anything had been done and was told by Dietary Aide B that she did not think anything had been done. RN C stated she encouraged Dietary Aide B to report it again. She said it would have been reported to Regional Director J at this time. She said it was her understanding that it was reported to Regional Director J, who responded that he was aware the incident had been investigated and unfounded. She said she was unaware if it had been reported to HHSC. She said Resident #1 had a history of being friendly with female residents since his admission. She said he would grab the female resident's hands and kiss them. She said she had never seen him grab Resident #2's breast. She said she had not received special instruction regarding Resident #1, nor had she been interviewed regarding the allegation of sexually inappropriate touching between Resident #1 and #2. During an interview on 11/01/24 at 12:01 PM Dietary Aide B stated she was aware of an instance where Resident #1 touched the breast of Resident #2 in the dining room. She said she reported the incident to the Interim DON. She said the incident happened right after Mother's Day in 2024. She said she had seen other inappropriate things from Resident #1. She said she had observed him touch Resident #2's breast more than one time. She said she observed when she opened the door that entered the dining room from the kitchen him touching Resident #2's breast, and when he saw her he put his hands down, and his face turned red. She said she immediately reported the incident to the Interim DON in the presence of LVN L. She explained to the Interim DON that this was not the first time Resident #1 had been appropriate with female residents. She said she told the Interim DON that the touching was against Resident #2's will. She said she knew this because Resident #2 did not participate; it was just Resident #1. She said when she reported the incident to the Interim DON, she was told by the Interim DON that she would speak to Resident #2. She said she was also told that because Resident #2 had a boyfriend (no longer at the facility at the time of the investigation), it was ok for Resident #2 to have two boyfriends if she wanted. She said the Interim DON said she would ask Resident #2 if she wanted two boyfriends. She said the Interim DON had also explained to her that the laws had changed. She said she was told that if Resident #2 could not say what happened and if she had memory loss or dementia, there was nothing they could do about it. She said the Interim DON told her to let her know if she) saw anything else. She said the former ADM was the administrator at the time of the incident. She said the Interim DON reported the incident to Regional Director J, and he spoke with her about it once. She said Regional Director J asked her what happened, she explained that the incident occurred under the Former ADM, and told her to let him know if it happened again. She said it had not happened again, but nothing was done. She said she had not received any special instructions or additional training on what to do regarding Resident #1. She said Regional Director J was the only person who ever asked her anything about the incident. She explained there was another incident involving Resident #1. Still, she did not report it because she was unsure if it was considered inappropriate touching. She said nothing had been done with the incident between Resident #1 and #2. She said she did report the incident between Resident #1 and #2 to the DM but was told for her to report the incident herself. She said her DM told her to report the incident because she did not personally see the incident. She said outside of the interview with the HHSC investigator, she felt the incident had not been thoroughly investigated. During an interview on 11/01/24 at 12:40 PM, Resident #2 stated no one had touched her inappropriately. She said she had a boyfriend but did not remember his name. She said she knew Resident #1, but he had never touched her inappropriately. She said if someone did touch her, she would tell the people at the front. She said no one had asked her any questions before the HHSC investigator about inappropriately being touched. During an interview on 11/01/24 at 1:25 PM, LVN F stated that she knew the incident between Resident #1 and Resident #2. She stated she was told about the incident by RN C. She said she could not remember the exact date of the incident but that RN C stated that it was reported to her (RN C) by Dietary Aide B. She (LVN F) stated that she was not questioned or trained in regard to Resident #1 but remembered that the Interim DON said to Dietary Aide B that Resident #2 could have more than one boyfriend if she wanted. She said the incident was also reported to Regional Director J, and it was her understanding that he did an investigation and unsubstantiated the incident, according to RN C. LVN F said Resident #1 had a history of flirting with female residents and holding their hands. She said she had not seen anything to indicate the other female residents were uncomfortable. She said no instructions had been given regarding the behavior of Resident #1 flirting or holding the female resident's hands. She said they told Resident #1 to leave the female residents alone. She said Resident #1 laughed about it. She said it appeared Resident #1 found humor because he reported to them that Resident #2 was his school teacher. During an interview on 11/01/24 at 2:59 PM, Regional Director I stated he did not know anything about a male resident touching the breast of a female resident. He said he could not recall a specific conversation with the Interim DON. He said he had multiple discussions with the Interim DON. He said the Former DON's last day was May 15th or 16th of 2024. He said there were 10 days without an administrator, and then Regional Director J came to run the facility. He said it was his expectation that if staff suspect or witness abuse, they should follow the facility policy. He said it should be investigated thoroughly. He said he was unaware of the allegation between Resident #1 and #2. He said the potential negative outcome for the residents would depend on the allegation. During an interview on 11/01/24 at 3:06 PM, Regional Director J stated he was unaware of any incident that occurred between Resident #1 and Resident #2 that involved breast touching. Regional Director J said he was aware that there was a resident who was no longer at the facility and felt that Resident #1 had stolen his woman (Resident #2). He said if there was an allegation of ANE, it should be investigated. He said investigating the incident was important to ensure the resident was safe. He said the investigation process should be documented. During an interview on 11/01/24 at 3:25 PM, Resident #1 stated he had never been questioned about inappropriate behavior or accused of doing anything inappropriate. He stated he did not have a girlfriend but all the ladies at the facility liked him. He said he recently turned [AGE] years old and found out he was a lesbian because he liked girls. He said he does not touch anyone who does not want to be touched. He said he had not touched anyone since he had been at the facility. During an interview on 11/01/24 at 4:43 PM, the DON stated he said he was unaware of any incident that occurred between Resident #1 and Resident #2. He said he knew Resident #1 would hold people's hands, but it was not specific to female residents. He said he was unaware that Resident #1 would kiss the female resident hands. During an interview on 11/01/24 at 4:55 PM, the ADM stated he had been trained and was familiar with the facility's ANE policy. He said he was unaware of the incident involving Resident #1 touching Resident #2's breast. He said the potential negative outcome was there could have been the continuation of abuse or whatever was going on. He said not following the abuse policy could place the resident at unnecessary risk. He said allegations of ANE should have been investigated. He said the system to monitor abuse was education and communication. He said he had not observed any of the behaviors of the residents discussed. He said he expected the facility abuse policy to be followed. He said allegations of ANE should have been investigated along with preventative measures put in place to protect residents involved. He said everyone was responsible for following the ANE policy, but the administration oversaw the investigation process. He said he did not have a reason why following the facility policy (investigating) was not conducted. He said the investigation process should have been documented if conducted. Resident #3 Record Review of Resident #3's face sheet, dated 11/01/24, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss). Record Review of Resident #3's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 15, indicating the resident was not cognitively impaired. Section E did not reveal any documented behaviors for Resident #3. Record Review of Resident #3's Quarterly MDS assessment dated [DATE], revealed under Section E did not reveal any documented behaviors for Resident #3. Record Review of Resident #3's nursing progress notes entered by LVN K dated 03/07/24 at 7:04 PM indicated Resident #3 was in the TV room and his pants was unzipped by Resident #5. The CNA (unidentified) hollered out for the residents to stop. Resident #3 did not attempt to stop Resident #5. Record Review of Resident #3's progress notes entered by the SW dated 03/12/24 at 11:36 AM indicated Resident #3 was in the activity room with a female resident unzipping his pants. It was reported that Resident #3 was allowing Resident #5 to unzip his pants. It was reported that Resident #5 had severe dementia and seeks out male residents in particular Resident #3. The SW discussed with Resident #3 about the issues of female resident having dementia and not understanding their actions. The SW informed Resident #3 about notifying staff entering the room and for him to leave the room if it happens again. Record review of Resident #3's care plan, dated 5/03/24, revealed a focused area, initiated on 05/03/24, Resident #3 had been sexually inappropriate allowing a female resident to unzip his pants in a community setting. The goal initiated on 05/03/24, was Resident #3 would have no evidence of sexually inappropriate behavior problems. The interventions included to intervene as necessary to protect the rights and safety of others, discuss the resident's behavior and monitor behavior episodes. Resident #4 Record Review of Resident #4's face sheet, dated 11/01/24, revealed a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of dementia (memory loss). Record Review of Resident #4's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 10, indicating the resident was moderately cognitively impaired. Section E did not reveal any documented behaviors for Resident #4. Record Review of Resident #4's Quarterly MDS assessment dated [DATE], revealed under Section E did not reveal any documented behaviors for Resident #4. Record review of Resident #4's progress notes dated from 03/02/24- 11/01/24 did not reveal any information concerning Resident #3 or the behavior of rubbing herself outside of her clothing. Record review of Resident #4's care plan, dated 09/19/24, did not reveal any information regarding her concerns for Resident #3 or any behaviors of her rubbing herself outside of her clothing near her genital area. During an interview on 11/01/24 at 9:00 AM, the ADM stated he said there had been no issues since he had been at the facility but that he had to educate Resident #3 on not being flirtatious as he had touched another resident's (Resident #4) knee, but nothing out of line. During an interview on 11/01/24 at 1:01 PM, Resident #4 stated she felt safe. She said there was a male who made her feel uncomfortable. She said she did not know his name. She stated no one asked her about him. She was unable to tell why he made her uncomfortable. She said no one had touched her inappropriately. She said that if someone did touch her, she thinks she would tell someone. During an interview on 11/01/24 at 1:25 PM, LVN F stated she said she could not remember if it was reported to her that Resident #4 was uncomfortable around Resident #3. She said she could not remember the date, but the incident occurred about a month ago. She said she could not remember which aide came to her. She said she observed Resident #3 sitting outside Resident #4's room and thought it was weird. She said Resident #4 was in her bed. She said she looked off for a moment, and when she looked back up, Resident #3 was gone. She said she asked the aide (unknown at the time) to go check on him because Resident #3 had an inappropriate sexual incident with another resident in the past. She said it was her understanding that Resident #3 and another Resident #5 were fondling each other. She said she wanted to ensure Resident #3 was not in the room with Resident #4. She said she did report the weird behavior observed by Resident #3 to Regional Director J. She said Resident #3 will follow and target Resident #5 than other residents. She said Regional Director J told her to keep an eye on Resident #3. She said no additional training was given regarding Resident #3. She said she reported it to Regional Director J because of Resident #3's past. She said she did not believe the incident between Resident #3 and #5 was mishandled. She did not know why she thought it was not handled correctly. During an interview on 11/01/24 at 1:37 PM, Resident #3 stated he had only been told about inappropriate touching one time since his admission. He said he did not want to name the other resident but that she had run her hands up his leg. He said he had no other issues since that incident about a year ago. He said he did not remember staring at any other female residents. He asked the HHSC investigator if she knew anyone who could be his girlfriend because he would like one. During an interview on 11/01/24 at 2:39 PM, LVN H stated a couple of weeks ago (exact date unknown) that she was coming from the outside patio and observed Resident #3 had his hand on Resident #4's knee. She said she reported the incident to the ADM because there had been some incidents in the past that included Resident #3 and inappropriate sexual behavior. She said it was known that Resident #3 liked to stare and watch female residents. She said he had a history with Resident #4, where he would watch her and stare at her outside of Resident #4s room. She said they naturally redirect Resident #3 but had never been explicitly trained on what to do with Resident #3. During an interview on 11/01/24 at 3:06 PM, Regional Director J stated if there was an allegation of ANE, it should be investigated. He said investigating the incident was important to ensure the resident was safe. He said the investigation process should be documented. He said he was unaware that Resident #4 reported that she felt unsafe around Resident #3 because this was not reported to him. During an interview on 11/01/24 at 4:43 PM, the DON stated he said he was unaware that Resident #4 was uncomfortable around Resident #3. He said their system to monitor ANE and the following of the facility's abuse policy was education through in-services. He said there are signs posted outside of the administration doors. He said if staff suspected or witnessed abuse, the allegation should be investigated. He said after the incident was reported, the allegation would be investigated and assessed, the resident evaluated, and all witnesses and potential witnesses would be interviewed. He said he did not have a reason why the abuse policy was not followed. He said the investigation was not conducted because he was unaware of the incidents. He said that being new, he was unaware that any of the incidents/allegations discussed had been investigated. He said he was unaware of Resident #3 flirtatious behavior. He was unaware that Resident #3 had an incident where he sat outside of Resident #4's room, which made her uncomfortable. He said nothing was brought up during stand-up meetings regarding the resident issues discussed. He said if there are new or ongoing behaviors, they are also reported during shift changes. He said they also had a nursing group message system. He said Resident #3 touching Resident #4 was not placed in the nursing group message. He said Resident #3 behavior of staring at Resident #4 was also not included in the group message because he did not know anything about it. He said he had not observed any of the behaviors discussed. During an interview on 11/01/24 at 4:55 PM, the ADM stated he had been trained and was familiar with the facility's ANE policy. He said he was aware that Resident #3 had touched Resident #4's leg, but at the time of the report, LVN H reassured him that there was nothing inappropriate. He said he was unaware of his history of staring at Resident #4 outside her door. He said at the time, LVN H reported more information on Resident #3's history. He said he did not interview anyone else outside of LVN H regarding Resident #3 touching Resident #4's leg. He said the potential negative outcome was there could have been the continuation of abuse or whatever was going on. He said not following the abuse policy could place the resident at unnecessary risk. He said the system to monitor abuse was education and communication. He said he had not observed any of the behaviors of the residents discussed. He said he expected the facility abuse policy to be followed. He said allegations of ANE should have been investigated. He said everyone was responsible for following the ANE policy, but the administration oversaw the investigation process. He said he did not have a reason why following the facility policy (investigating) was not conducted. He said the investigation process should have been documented if conducted. During an interview on 11/01/24 at 5:34 PM, the Corporate MDS Consultant stated she went through each resident's progress notes and found the incident between Resident #3 and Resident #5. She said she was unaware if the incident had been reported to HHSC. She said she did not follow up with anything else because the note indicated it had been reported to the Interim DON and the Former ADM. She said she did not follow up with either of them. She said she was unsure if the incident had been investigated. She said she did not assess or speak with the residents. During an interview on 11/01/24 at 5:40 PM, Regional Director J stated he did not find anything showing that the incident between Resident #3 and Resident #5 was investigated. Resident #5 Record Review of Resident #5's face sheet, dated 11/01/24, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with the following diagnoses: dementia (memory loss) and high risk heterosexual behavior. Record Review of Resident #5's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 04, indicating the resident was severely cognitively impaired. Section E did not reveal any documented behaviors for Resident #5. Record Review of Resident #5's Quarterly MDS assessment dated [DATE], revealed under Section E did not reveal any documented behaviors for Resident #5. Record review of Resident #5's Order Summary Report, dated 11/01/24, reflected the resident was to take 1 tablet 2 times a day by mouth of Depakote for dementia with sexual issues related to dementia; Ordered 3/07/2024. Record Review of Resident #5's nursing progress notes entered by LVN K dated 03/07/24 at 6:00 PM indicated Resident #5 was observed unzipping Resident #3's pants and was about to put her hands in his pants. Resident #3 reported

Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) for 4 of 7 residents (Resident #1, #2, 3, and #5) reviewed for abuse. A. The Interim DON failed to follow the facility's abuse policy by not reporting the incident involving Resident #1 and Resident #2's involvement in inappropriate sexual touching reported by Dietary Aide B on an unknown date to HHSC. B. The Former ADM failed to follow the facility's abuse policy by not reporting the incident involving Resident #1 and Resident #2's involvement in inappropriate sexual touching reported by Dietary Aide B on an unknown date to HHSC. C. The Interim DON failed to follow the facility's abuse policy by not reporting the incident involving Resident #3 and Resident #5's involvement of inappropriate touching reported by an unknown staff on 03/07/24 to HHSC. D. The Former ADM failed to follow the facility's abuse policy by not reporting the incident involving Resident #3 and Resident #5's involvement of inappropriate touching reported by an unknown staff on 03/07/24 to HHSC. These failures could place residents as risk for abuse and neglect. Findings included: Resident #1 Record Review of Resident #1's face sheet, dated 11/01/24, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss). Record Review of Resident #1's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 14, indicating the resident was not cognitively impaired. Section E did not reveal any documented behaviors for Resident #1. Record Review of Resident #1's Quarterly MDS assessment dated [DATE], revealed under Section E did not reveal any documented behaviors for Resident #1. Record review of Resident #1's progress notes dated from 03/02/24- 11/01/24 did not reveal any information regarding the allegation of touching Resident #2 breast or his flirtatious behavior with female residents. Record Review of Resident #1's nursing progress notes entered by the Interim DON dated 05/14/24 at 11:47 PM indicated she spoke with the SW to speak with Resident #1 about calling female staff pet names. A letter was given outlining the facility expectations regarding not calling female staff pet names. Record review of Resident #1's care plan, dated 05/14/24, did not reveal any information regarding his flirtatious behavior towards female residents or allegation regarding touching Resident #2's breast. Resident #2 Record Review of Resident #2's face sheet, dated 11/01/24, revealed a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE], with the following diagnoses: dementia (memory loss), and depression (prolonged period of sadness). Record Review of Resident #2's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 08, indicating the resident was moderately cognitively impaired. Section E did not reveal any documented behaviors for Resident #2. Record Review of Resident #2's Quarterly MDS assessment dated [DATE], revealed under Section E did not reveal any documented behaviors for Resident #2. Record review of Resident #2's care plan, dated 08/06/24, did not reveal any information regarding her being touched by another male resident .Further review revealed a focused area, initiated on 08/06/24, that indicated Resident #2 wanted to be in an affectionate relationship with male residents. The goal initiated on 08/06/24 revised 10/18/24, was based on family wishes for Resident #2 to visit with male resident (unidentified) in the common area. The interventions initiated 08/06/24 included avoid improper touching, avoid going into other residents room, keeping resident family updated with relationship status and talking often about being happy when she is in a relationship with male residents. Record review of Resident #2's progress notes dated from 03/02/24- 11/01/24 did not reveal any information regarding the allegation of her breast being touched by Resident #1. Record Review of Resident #2's nursing progress notes entered by LVN H dated 08/02/24 at 7:02 PM indicated Resident #2 was in a male (unidentified) room sitting in her wheelchair and a CNA (unidentified) observed the male resident with his pants around his ankles claiming that he was going to have sex with her. During an interview on 11/01/24 at 9:55 AM, the DM stated Dietary Aide B did report to her that Resident #1 had grabbed Resident #2's breast. She said she was unsure of the exact date. She said she did not witness it but considered inappropriate touching. She said when it was reported to her, she told Dietary Aide B that someone needed to know. She said the ADM was not the administrator and did not know which nurse Dietary Aide B reported the incident to. She said she did not personally report the incident to anyone because she did not personally observe the incident. She said it was her understanding that Dietary Aide B reported the incident to Regional Director J and the charge nurse. She said she could not remember who the charge nurse was. She said she had observed Resident #1 to be social but not overly attentive to any one resident. She said she had not received any special instructions regarding Resident #1. She said although she did not remember the exact date, she did remember the day Dietary Aide B reported the incident. Resident #2 seemed fine and not in any distress. She said she felt if Resident #2 felt threatened, she could tell someone. She said the ADM was the abuse preventionist and had been trained that if she suspected or witnessed abuse, she was to report the allegation to the ADM immediately. She said she had not been interviewed by anyone regarding the incident. During an interview on 11/01/24 at 11:06 AM, the Interim DON stated she no longer worked at the facility. She said she was notified of the incident between Resident #1 and Resident #2. She said she was unsure of the exact date of the incident between Resident #1 and #2, but it was first reported when the Former ADM was employed by dietary Aide B. She said an investigation was conducted, and it was unfounded by the Former ADM. She said Regional Director J took over after the former ADM left. She said when Regional Director J took over, the incident involving Resident #1 and #2 was brought back up. She said she interviewed Residents (Residents #1 and #2), and nothing was found. She said she was unable to list all she interviewed as she did not work there anymore. She said this may have been in April or May 2024. She said she remembered when she interviewed Resident #1 and Resident #2, both residents denied anything happening and therefore unfounded the incident. She said there were concerns because each time the new administration would come, the incident of Resident #1 touching Resident #2's breast would come up. She said she did not believe anything had happened because no other allegations had been made since the report. She said it was her understanding that Resident #1 had not approached Resident #2 since the allegation. She said she was unsure why the allegation continues to be addressed, and it seemed to be the kitchen staff that had concerns. She said during her investigation, she found that the people named to be present were not working the day of the incident. The Interim DON said she could not list the people who worked the day of the incident, the date of the incident, and anyone she interviewed, but she unfounded the incident. She said this had been reported to her a total of three times, and she did not report the incident to HHSC during any of those times. She said she did not report the allegation of sexually inappropriate touching because Residents #1 and #2 stated the incident had not occurred, and they unfounded the incident. She said she did keep her eye on Resident #1. She said Family Member G had been notified. She said she had not received any additional reports that Resident #1 had touched any other residents. She said she did not know if she had any written documentation to support her efforts to address the allegations of sexually inappropriate touching from Resident #1. She said she never typed anything up. She said she should have typed something in his progress notes since this was brought up many times. She said she could not pinpoint specific training related to the incident because she had done so many in-services on ANE. She said she did discuss the incident with Regional Director I, and they had decided the incident was not a facility reportable incident because both residents had dementia, and both parties stated nothing happened. She said they agreed that since the kitchen staff kept reporting it, it was retaliation. She said it was not reported to HHSC because there was no proof that it happened and no witnesses. She said that it was known that Dietary Aide B was married into the family of Resident #1 and that she must also protect Resident #1's rights. She said the purpose of following the abuse policy, reporting, and investigating allegations of ANE was to protect the population from ANE, make sure their needs were met, and avoid neglect. She said she had been trained that it was all or none. She said this meant that she was to collect data, have credible witnesses, and then report the incident to HHSC. She said she felt Resident #1 was being painted as a perpetrator based on community rumors. She said she wanted to also protect Resident #1 from false allegations. In regard to documentation, she said she would have to see if she had anything. (The Interim DON did not provide any documentation during the investigation) During an interview on 11/01/24 at 11:55 AM, RN C stated she was notified a few months ago (unknown exact date and time) by Dietary Aide B that she witnessed Resident #1 touching Resident #2's breast. She said she was told by Dietary Aide B that it did not seem mutual. RN C said she asked Dietary Aide B if she had reported the incident to the Interim DON as they did not have an administrator at the time. She said Dietary Aide B said she had. RN C asked if anything had been done and was told by Dietary Aide B that she did not think anything had been done. RN C stated she encouraged Dietary Aide B to report it again. She said it would have been reported to Regional Director J at this time. She said it was her understanding that it was reported to Regional Director J, who responded that he was aware the incident had been investigated and unfounded. She said she was unaware if it had been reported to HHSC. She said Resident #1 had a history of being friendly with female residents since his admission. She said he would grab the female resident's hands and kiss them. She said she had never seen him grab Resident #2's breast. She said she had not received special instruction regarding Resident #1, nor had she been interviewed regarding the allegation of sexually inappropriate touching between Resident #1 and #2. During an interview on 11/01/24 at 12:01 PM Dietary Aide B stated she was aware of an instance where Resident #1 touched the breast of Resident #2 in the dining room. She said she reported the incident to the Interim DON. She said the incident happened right after Mother's Day in 2024. She said she had seen other inappropriate things from Resident #1. She said she had observed him touch Resident #2's breast more than one time. She said she observed when she opened the door that entered the dining room from the kitchen him touching Resident #2's breast, and when he saw her he put his hands down, and his face turned red. She said she immediately reported the incident to the Interim DON in the presence of LVN L. She explained to the Interim DON that this was not the first time Resident #1 had been appropriate with female residents. She said she told the Interim DON that the touching was against Resident #2's will. She said she knew this because Resident #2 did not participate; it was just Resident #1. She said when she reported the incident to the Interim DON, she was told by the Interim DON that she would speak to Resident #2. She said she was also told that because Resident #2 had a boyfriend (no longer at the facility at the time of the investigation), it was ok for Resident #2 to have two boyfriends if she wanted. She said the Interim DON said she would ask Resident #2 if she wanted two boyfriends. She said the Interim DON had also explained to her that the laws had changed. She said she was told that if Resident #2 could not say what happened and if she had memory loss or dementia, there was nothing they could do about it. She said the Interim DON told her to let her know if she) saw anything else. She said the former ADM was the administrator at the time of the incident. She said the Interim DON reported the incident to Regional Director J, and he spoke with her about it once. She said Regional Director J asked her what happened, she explained that the incident occurred under the Former ADM and told her to let him know if it happened again. She said it had not happened again, but nothing was done. She said she had not received any special instructions or additional training on what to do regarding Resident #1. She said Regional Director J was the only person who ever asked her anything about the incident. She explained there was another incident involving Resident #1. Still, she did not report it because she was unsure if it was considered inappropriate touching. She said nothing had been done with the incident between Resident #1 and #2. She said she did report the incident between Resident #1 and #2 to the DM but was told for her to report the incident herself. She said her DM told her to report the incident because she did not personally see the incident. She said outside of the interview with the HHSC investigator, she felt the incident had not been thoroughly investigated. During an interview on 11/01/24 at 12:40 PM, Resident #2 stated no one had touched her inappropriately. She said she had a boyfriend but did not remember his name. She said she knew Resident #1, but he had never touched her inappropriately. She said if someone did touch her, she would tell the people at the front. She said no one had asked her any questions before the HHSC investigator about inappropriately being touched. During an interview on 11/01/24 at 2:59 PM, Regional Director I stated he did not know anything about a male resident touching the breast of a female resident. He said he could not recall a specific conversation with the Interim DON. He said he had multiple discussions with the Interim DON. He said the Former DON's last day was May 15th or 16th of 2024. He said there were 10 days without an administrator, and then Regional Director J came to run the facility. He said it was his expectation that if staff suspect or witness abuse, they should follow the facility policy. He said it should be reported to HHSC. He said he was unaware of the allegation between Resident #1 and #2. He said the potential negative outcome for the residents would depend on the allegation. During an interview on 11/01/24 at 1:25 PM, LVN F stated that she knew the incident between Resident #1 and Resident #2. She stated she was told about the incident by RN C. She said she could not remember the exact date of the incident but that RN C stated that it was reported to her (RN C) by Dietary Aide B. She (LVN F) stated that she was not questioned or trained in regard to Resident #1 but remembered that the Interim DON said to Dietary Aide B that Resident #2 could have more than one boyfriend if she wanted. She said the incident was also reported to Regional Director J, and it was her understanding that he did an investigation and unsubstantiated the incident, according to RN C. LVN F said Resident #1 had a history of flirting with female residents and holding their hands. She said she had not seen anything to indicate the other female residents were uncomfortable. She said no instructions had been given regarding the behavior of Resident #1 flirting or holding the female resident's hands. She said they told Resident #1 to leave the female residents alone. She said Resident #1 laughed about it. She said it appeared Resident #1 found humor because he reported to them that Resident #2 was his school teacher. She (LVN F) stated that she was not questioned or trained in regard to Resident #1 but remembered that She said the incident was also reported to Regional Director J, and it was her understanding that he did an investigation and unsubstantiated the incident, according to RN C. During an interview on 11/01/24 at 3:06 PM, Regional Director J stated he was unaware of any incident that occurred between Resident #1 and Resident #2 that involved breast touching. Regional Director J said he was aware that there was a resident who was no longer at the facility and felt that Resident #1 had stolen his woman (Resident #2). He said if there was an allegation of ANE, it should be reported to HHSC. During an interview on 11/01/24 at 3:25 PM, Resident #1 stated he had never been questioned about inappropriate behavior or accused of doing anything inappropriate. He stated he did not have a girlfriend but all the ladies at the facility liked him. He said he recently turned [AGE] years old and found out he was a lesbian because he liked girls. He said he does not touch anyone who does not want to be touched. He said he had not touched anyone since he had been at the facility. During an interview on 11/01/24 at 4:43 PM, the DON stated he said he was unaware of any incident that occurred between Resident #1 and Resident #2. He said he knew Resident #1 would hold people's hands, but it was not specific to female residents. He said he was unaware that Resident #1 would kiss the female resident hands. During an interview on 11/01/24 at 4:55 PM, the ADM stated he had been trained and was familiar with the facility's ANE policy. He said he was unaware of the incident involving Resident #1 touching Resident #2's breast. He said the potential negative outcome was there could have been the continuation of abuse or whatever was going on. He said not following the abuse policy could place the resident at unnecessary risk. He said the system to monitor abuse was education and communication. He said he had not observed any of the behaviors of the residents discussed. He said he expected the facility abuse policy to be followed. He said it should have been reported to HHSC. He said everyone was responsible for following the ANE policy, but the administration oversaw the investigation process and reported the allegation to HHSC. He said he did not have a reason why following the facility policy (reporting to HHSC) was not conducted. He said the investigation process should have been documented if conducted. Resident #3 Record Review of Resident #3's face sheet, dated 11/01/24, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss). Record Review of Resident #3's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 15, indicating the resident was not cognitively impaired. Section E did not reveal any documented behaviors for Resident #3. Record Review of Resident #3's Quarterly MDS assessment dated [DATE], revealed under Section E did not reveal any documented behaviors for Resident #3. Record Review of Resident #3's nursing progress notes entered by LVN K dated 03/07/24 at 7:04 PM indicated Resident #3 was in the TV room and his pants was unzipped by Resident #5. The CNA (unidentified) hollered out for the residents to stop. Resident #3 did not attempt to stop Resident #5. Record Review of Resident #3's progress notes entered by the SW dated 03/12/24 at 11:36 AM indicated Resident #3 was in the activity room with a female resident unzipping his pants. It was reported that Resident #3 was allowing Resident #5 to unzip his pants. It was reported that Resident #5 had severe dementia and seeks out male residents in particular Resident #3. The SW discussed with Resident #3 about the issues of female resident having dementia and not understanding their actions. The SW informed Resident #3 about notifying staff entering the room and for him to leave the room if it happens again. Record review of Resident #3's care plan, dated 5/03/24, revealed a focused area, initiated on 05/03/24, Resident #3 had been sexually inappropriate allowing a female resident to unzip his pants in a community setting. The goal initiated on 05/03/24, was Resident #3 would have no evidence of sexually inappropriate behavior problems. The interventions included to intervene as necessary to protect the rights and safety of others, discuss the resident's behavior and monitor behavior episodes. Resident #5 Record Review of Resident #5's face sheet, dated 11/01/24, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with the following diagnoses: dementia (memory loss) and high risk heterosexual behavior. Record Review of Resident #5's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 04, indicating the resident was severely cognitively impaired. Section E did not reveal any documented behaviors for Resident #5. Record Review of Resident #5's Quarterly MDS assessment dated [DATE], revealed under Section E did not reveal any documented behaviors for Resident #5. Record review of Resident #5's Order Summary Report, dated 11/01/24, reflected the resident was to take 1 tablet 2 times a day by mouth of Depakote for dementia with sexual issues related to dementia; Ordered 3/07/2024. Record Review of Resident #5's nursing progress notes entered by LVN K dated 03/07/24 at 6:00 PM indicated Resident #5 was observed unzipping Resident #3's pants and was about to put her hands in his pants. Resident #3 reported he had his hand in Resident #5's shirt. This information was reported to the Former ADM and Former Interim DON. Record review of Resident #5's care plan, dated 5/02/24, revealed a focused area, initiated on 05/02/24, Resident #5 had a behavior problem of sexual inappropriate r/t dementia. The goal initiated on 05/02/24, was that Resident #5 would have no evidence of behavior problems. The Interventions included administering Depakote, caregivers provide positive interaction, discuss resident's behavior, and monitor behavior. During an interview on 11/01/24 at 9:00 AM, the ADM stated he was the abuse preventionist. He stated he had introduced himself to all residents. He said if staff suspect or witness abuse, they should report it to him or the DON. He said the DON was the alternate abuse preventionist. He said if it were after hours, the staff would report to the charge nurse on duty, and the charge nurse would contact him or the DON. He said he had not had any facility-reported incidents since he had been at the facility. He stated he had been at the facility for a few weeks. He said when he does report any incident to HHSC, he kept a physical folder with all the information in it. He said there were no facility-reported incidents to his knowledge when he came to the facility a few weeks ago. He stated he was responsible for the facility incident reporting process. He said if an allegation of ANE were received, he would report it to HHSC. He said the system they use to monitor abuse allegations was the most recent abuse provider letter provided by HHSC. He said the potential negative outcome of not following the facility's abuse policy was abuse could continue to persist, and things could get worse for the resident. He said that although he was new to the physical facility, they were under the same management company. The ADM stated he said there had been no issues since he had been at the facility but that he had to educate Resident #3 on not being flirtatious as he had touched another resident's knee, but nothing out of line. During an interview on 11/01/24 at 12:50 PM, Resident #5 stated she felt safe. She said the staff treated her well. She stated she did not need the HHSC investigator to investigate anything for her. She said no residents had inappropriately touched her, and she had not inappropriately touched anyone. She said she felt if she had been inappropriately touched, she would tell someone. She stated she would tell the staff at the front. She said she had not had any incident of inappropriate touching or sexual abuse. During an interview on 11/01/24 at 1:37 PM, Resident #3 stated he had only been told about inappropriate touching one time since his admission. He said he did not want to name the other resident but that she had run her hands up his leg. He said he had no other issues since that incident about a year ago. He said he did not remember staring at any other female residents. He asked the HHSC investigator if she knew anyone who could be his girlfriend because he would like one. During an interview on 11/01/24 at 3:06 PM, Regional Director J stated if there was an allegation of ANE, it should be reported to HHSC. During an interview on 11/01/24 at 4:43 PM, the DON stated their system to monitor ANE and ensuring staff were following of the facility's abuse policy was education through in-services. He said there are signs posted outside of the administration doors. He stated not following the facility's abuse policy, the potential negative outcome was actual harm or something detrimental could happen. He said if staff suspected or witnessed abuse, the allegation should be reported to HHSC. He said he did not have a reason why the abuse policy was not followed. He said he had been at the facility since 10/11/24 but was familiar with and had been trained on the facility's abuse policy. He said their system to monitor ANE and the following of the facility's abuse policy was education through in-services. He said that being new, he was unaware that any of the incidents/allegations discussed had been reported to HHSC. He said he was unaware of Resident #3 flirtatious behavior. He said nothing was brought up during stand-up meetings regarding the resident issues discussed. He said if there are new or ongoing behaviors, they are also reported during shift changes. He said they also had a nursing group message system. He said he had not observed any of the behaviors discussed. During an interview on 11/01/24 at 4:55 PM, the ADM stated he had been trained and was familiar with the facility's ANE policy. He said not following the abuse policy could place the resident at unnecessary risk. He said the system to monitor abuse was education and communication. He said he had not observed any of the behaviors of the residents discussed. He said he expected the facility abuse policy to be followed. He said allegations of ANE should have been reported to HHSC. He said everyone was responsible for following the ANE policy, but the administration oversaw the investigation process and reported the allegation to HHSC. He said he did not have a reason why following the facility policy (reporting to HHSC) was not conducted. During an interview on 11/01/24 at 5:40 PM, Regional Director J stated he did not find anything showing that the incident between Resident #3 and Resident #5 was reported to HHSC or investigated. During an interview on 11/01/24 at 5:34 PM, the Corporate MDS Consultant stated she went through each resident's progress notes and found the incident between Resident #3 and Resident #5. She said she was unaware if the incident had been reported to HHSC. She said she did not follow up with anything else because the note indicated it had been reported to the Interim DON and the Former ADM. She said she did not follow up with either of them. She said she was unsure if the incident had been investigated. She said she did not assess or speak with the residents. Record review of the facility policy, Abuse Prevention Program, Revised December 2016 revealed: Policy Statement Our Residents have the right to be free from abuse, neglect . Policy Interpretation and Implementation As a part of the resident abuse prevention, the administration will: Protect our residents from abuse by anyone including, but not necessarily limited to: other residents . Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Identify and assess all possible incidents of abuse; Report any allegations of abuse within timeframes as required by federal requirements; Record review of the facility policy, Abuse Investigation and Reporting, revised July 2017 revealed: Policy Statement All reports of resident abuse , neglect, exploitation, misappropriation of resident property, mistreatment and or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies . Policy interpretation If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported . Reporting All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility The resident's representative (sponsor) of record An alleged violation of abuse, neglect . Two hours if the alleged violation involves abuse There were no provider investigation reports available for review that involved any of the residents listed in the sample as of 11/04/24.

Based on interviews and record review, the facility failed to develop and implement a person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 7 residents (Resident #1 and #4) reviewed for comprehensive care plans. Resident #1's comprehensive care plan did not include his known behavior for sexual inappropriateness (kissing residents hands and the alleged touching of the breast) and flirtatious behavior towards female residents and specifically Resident #2. Resident #4's comprehensive care plan did not include her known behavior for sexual inappropriateness (masturbating on the outside of her clothing) in common areas. This failure could place residents at risk for not having their individualized needs met. The findings included: Resident #1 Record Review of Resident #1's face sheet, dated 11/01/24, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss). Record Review of Resident #1's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 14, indicating the resident was not cognitively impaired. Section E did not reveal any documented behaviors for Resident #1. Record Review of Resident #1's Quarterly MDS assessment dated [DATE], revealed Section E did not reveal any documented behaviors for Resident #1. Record review of Resident #1's progress notes dated from 03/02/24- 11/01/24 did not reveal any information regarding the allegation of touching Resident #2's breast or his flirtatious behavior with female residents but revealed the following: Record Review of Resident #1's nursing progress notes entered by the Interim DON dated 05/14/24 at 11:47 PM indicated she spoke with the SW to speak with Resident #1 about calling female staff pet names. A letter was given outlining the facility expectations regarding not calling female staff pet names. Record review of Resident #1's care plan, dated 05/14/24, did not reveal any information regarding his flirtatious behavior towards female residents or allegation regarding touching Resident #2's breast. There were no observations of Resident #1 having inappropriate contact with female residents during the visit. Resident #2 Record Review of Resident #2's face sheet, dated 11/01/24, revealed a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE], with the following diagnoses: dementia (memory loss), and depression (prolonged period of sadness). Record Review of Resident #2's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 08, indicating the resident was moderately cognitively impaired. Section E did not reveal any documented behaviors for Resident #2. Record Review of Resident #2's Quarterly MDS assessment dated [DATE], revealed Section E did not reveal any documented behaviors for Resident #2. Record review of Resident #2's progress notes dated from 03/02/24- 11/01/24 did not reveal any information regarding the allegation of her breast being touched by Resident #1. Record Review of Resident #2's nursing progress notes entered by LVN H dated 08/02/24 at 7:02 PM indicated Resident #2 was in a male (unidentified) room sitting in her wheelchair and a CNA (unidentified) observed the male resident with his pants around his ankles claiming that he was going to have sex with her. Record review of Resident #2's care plan, dated 08/06/24, did not reveal any information regarding her being touched by another male resident. Further review revealed a focused area, initiated on 08/06/24, Resident #2 wanted to be in an affectionate relationship with male residents. The goal initiated on 08/06/24 revised 10/18/24, was based on family wishes for Resident #2 to visit with male resident (unidentified) in the common area. The Interventions initiated 08/06/24 included avoid improper touching, avoid going into other residents room, keeping resident family updated with relationship status and talking often about being happy when she is in a relationship with male residents. Resident #4 Record Review of Resident #4's face sheet, dated 11/01/24, revealed a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE], with the following diagnoses: dementia (memory loss). Record Review of Resident #4's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 10, indicating the resident was moderately cognitively impaired. Section E did not reveal any documented behaviors for Resident #4. Record Review of Resident #4's Quarterly MDS assessment dated [DATE], revealed Section E did not reveal any documented behaviors for Resident #4. There were no observations observed during the visit of Resident #4 masturbating on the outside of her clothing. During an interview on 11/01/24 at 9:22 AM, [NAME] A stated Resident #1 was a ladies' man. She said he had a history of flirting since his admission. [NAME] A stated there was a history between Resident #1 and #2. She said Resident #1's attempt to flirt and approach Resident #2 caused issues with the other resident, who was no longer at the facility. She said she had not been given any instructions or training regarding Resident #1. She said outside of the incident (Resident #1 touching Resident #2's breast) with Resident #2, she had seen him touch other residents' hands. She said Resident #4 would play with herself. She said she had been told (she could not remember by who) that she would do this when she was nervous. She said this was a known behavior (unable to report for how long) but that male residents would watch her rub on herself in a circular motion. She said staff talked to her about it as much as they could. She said there was an indication that she was about to do it because she would raise her leg. At first, she thought she (resident #4) was itching, but she believed she was checked to rule that out. She said the staff knew to redirect her, offer her a drink, or engage her in another activity. She said she had not received additional training about Resident #4's behavior, but some staff knew how to redirect her. She said if they did not see her raise her legs, it was easy to identify because all the male resident's heads would be turned towards her doing that behavior in the dining room or any common area. She said no other residents have become offended or complained that she was aware of. She said she could not confirm if the other residents were looking at Resident #4 for pleasure or out of shock. During an interview on 11/01/24 at 11:33 AM, CNA E stated over the past month, Resident #4 had a behavior of rubbing herself in her genital area. She said other staff had also noticed it. She said naturally, she and other staff would redirect her. She said they had not received specific training regarding Resident #4 rubbing her genital area. She said they had general knowledge to redirect her since sometimes she would do this in common areas. She said Resident #3 would sit and watch Resident #4 rub herself in her genital area. She said Resident #1 was her (CNA E) family member, and although she had not seen him touch the breasts of anyone, he was known as a big flirt. She said she had observed Resident #1 hold hands with Resident #2 but that Resident #2 was friendly and did not care. She said Resident #2 had a boyfriend who was no longer at the facility, and Resident #1 would stir the pot and upset the resident who was no longer at the facility by flirting with Resident #2. During an interview on 11/01/24 at 11:55 AM, RN C stated Resident #1 had a history of being friendly with female residents since his admission. She said he would grab the female resident's hands and kiss them. She said she had never seen him grab Resident #2's breast. She said she had not received special instruction regarding Resident #1. During an interview on 11/01/24 at 12:01 PM Dietary Aide B stated she was aware of an instance where Resident #1 touched the breast of a female Resident #2 in the dining room. She said she reported the incident to the Interim DON. She said the incident happened right after Mother's Day in 2024. She said she had seen other inappropriate things from Resident #1. She said she had observed him touch Resident #2's breast more than one time. She said she observed when she opened the door that entered the dining room from the kitchen him touching Resident #2's breast, and when he saw her observe her, he put his hands down, and his face turned red. She said she immediately reported the incident to the Interim DON in the presence of LVN L. She explained to the Interim DON that this was not the first time Resident #1 had been inappropriate with female residents. She said she told the Interim DON that the touching was against Resident #2's will. She said she knew this because Resident #2 did not participate; it was just Resident #1. She said that when she reported the incident to the Interim DON, she was told by the Interim DON that she would speak to Resident #2 about it. She said she was also told that because Resident #2 had a boyfriend (no longer at the facility at the time of the investigation), it was ok for Resident #2 to have two boyfriends if she wanted. During an interview on 11/01/24 at 12:40 PM, Resident #2 stated that no one had touched her inappropriately. She said she had a boyfriend but did not remember his name. She said she knew Resident #1, but he had never touched her inappropriately. During an interview on 11/01/24 at 1:01 PM, Resident #4 stated there was a male who made her feel uncomfortable. She said she did not know his name. She was unable to tell why he made her uncomfortable. During an interview on 11/01/24 at 1:25 PM, LVN F said that Resident #1 had a history of flirting with female residents and holding their hands. She said she had not seen anything to indicate that the other female residents were uncomfortable. She said no instructions had been given regarding the behavior of Resident #1 flirting or holding the female resident's hands. She said they told Resident #1 to leave the female residents alone. She said Resident #1 laughed about it. She said it appeared that Resident #1 found humor because he reported to them that Resident #2 was his school teacher. During an interview on 11/01/24 at 2:39 PM, LVN H said he (Resident #1) had a history of being with the female residents throughout the day. She said he liked to sit with them. She was unaware if Resident #1 had touched Resident #2's breast. During an interview on 11/01/24 at 3:25 PM, Resident #1 stated he was a lesbian because he liked girls. He said he does not touch anyone who does not want to be touched. He said he had not touched anyone since he had been at the facility. During an interview on 11/01/24 at 4:43 PM, the DON stated he was familiar with and trained on the facility's care plan process. He said the potential negative outcome of not implementing the care plan process was that the needs of the residents may not be met. He said the purpose of having a care plan was to meet the needs of the resident. He said he was unaware that Resident #4 had a behavior where she would rub herself near her genital area in public areas in the facility. He said he knew Resident #1 would hold people's hands, but it was not specific to female residents He said the system to monitor care plans was to bring up behaviors and care plans during stand-up meetings. He said nothing was brought up during stand-up meetings regarding the resident issues discussed. He said if there are new or ongoing behaviors, they are also reported during shift changes. He said administration staff had the ability to add behavior to monitor in PCC (electronic medical record). He said they also had a nursing group message system. He said he had not observed any of the behaviors discussed. He said he expected the care plan to be up-to-date and accurate. He said revisions should also be done timely. He said the care plan should be updated within 24 hours for revisions. He said he did not have any reason why the care plans were not completed. He said the potential negative outcome for Resident #4 if she had the behavior was staff may not know how to intervene. During an interview on 11/01/24 at 4:55 PM, the ADM stated he was familiar with the facility's care plan policy and had been trained. He said he was newer to the facility and had not physically laid eyes on a lot of the care plans at the facility. He said the care plan should customize the residents' care. He said the potential negative outcome regarding not care planning Resident #4's behavior was she may not be given the proper privacy. The ADM said he had not found staff that knew about Resident #4's behavior of rubbing herself near her genital area and other residents watching. He said that regarding Resident #1, staff may not know how to watch out for or address the flirtatious behavior. He said he was unaware of all the behaviors discussed. He said the scheduled care plan meetings were the system to monitor care plans. He said he expected the care plans to be updated, current, and accurate. He said he believed a revision or change should be updated within 24 hours. He said the MDS Coordinator was responsible and out on vacation. He said he did not have a reason why the care plans were not updated or revised. During an interview on 11/11/24 at 4:24 PM, the MDS Coordinator stated she was the MDS Coordinator and on vacation until 11/12/24. She said she was unaware of Resident #4's behavior of rubbing herself outside of her clothing near her genital area. She said she knew Resident #1 had flirtatious behavior and was holding female residents' hands. She said she only knew he did this with Resident #2. She said if there were missing care plans or revisions, it was because, for a while, she was not only the MDS coordinator, but she was also the assistant director of nursing and responsible for scheduling staff. She said she was sometimes up late at night trying to find staff. She said she forgot to add Resident #1's behavior of being flirtatious. She said she had been trained and was familiar with the facility policy on care plans and care plan revisions. She said she expected all the care plans to be accurate and up to date. She said if the care plan was not up to date and accurate, then staff would not know what to do to meet the needs of the residents. She said staff had been trained to come to her with any new behaviors so that they could care plan. She said that recently, with the new administration, staff will go to them, which may cause some information to be missed. She said she did not have a system at the time of the interview to monitor or review care plans because she was doing so many roles. Record review of facility policy, Care Plans, Comprehensive Person Centered, Revision March 2022, revealed: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, . Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 16 residents (Resident #31) reviewed for care plans. The facility failed to ensure Resident #31's care plan reflected the resident's current code status. This failure could place residents at risk of not receiving appropriate care to meet their current needs. Findings include: Resident # 31: Record review of a facility face sheet for Resident #31 dated [DATE] indicated that she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included the following: vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), facial weakness following other cerebrovascular disease, major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), generalized anxiety disorder (mental health condition that causes fear, a constant feeling of being overwhelmed and excessive worry), essential primary hypertension (abnormally high blood pressure that's not the result of a medical condition), and chronic atrial fibrillation, unspecified (irregular and often very rapid heart rhythm). Record review of Resident #31's Quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed under Section C Cognitive Patterns, a BIMS score of 13 indicating the resident was slightly, cognitively impaired. Record review of physician orders dated [DATE] for Resident #31 indicated a Code Status of DNR. Record review of Resident #31's Out of Hospital Do Not Resuscitate (OOH-DNR) form dated [DATE] revealed it was completed by a qualified relative, signed by a physician, and signed by two witnesses. Record review of Resident #31's care plan dated [DATE] with a revision date of [DATE] revealed a care plan focus of Full Code with a goal that stated residents wishes will be honored, and the intervention stated, Resident wishes will be respected and acted upon. CPR will be performed if need arises. During an interview on [DATE] at 11:55 AM, the ADMIN and the DON stated ADON is responsible for ensuring care plans were completed and updated accurately. The ADMIN stated the ADON was not working on this day and was not available for interview. The ADMIN stated the ADON was the MDS nurse as well. The ADMIN stated the ADON was having trouble keeping up with the care plans. The ADMIN stated the contracted personnel were not located in the facility. The ADMIN stated Resident #31 had a code status of DNR. The DON confirmed this. The ADMIN and DON both stated they were unaware the care plan for Resident #31 indicated a code status of Full Code (medical directive that instructs a patient's healthcare team to perform all possible measures to save the patient's life in the event of a medical emergency). The ADMIN stated Resident #31 was previously a Full Code status but was changed to DNR once she was placed on Hospice services. The ADMIN stated this change should have been updated on Resident #31's care plan as soon as the change was effective. The DON stated the change should have been updated on the care plan immediately. The ADMIN stated the ADON should have received training on completing and updating care plans at some point, but he was unsure of when that occurred. The ADMIN stated the ADON received ongoing training on how to complete and update care plans and she should have known these updates were needed. The ADMIN stated updating care plans when changes occur was included in the facility's policy related to care plans. The ADMIN stated the facility had an MDS and care plan consultant that monitored the completion of care plans to help ensure they are completed and updated, but he was unsure why these updated were not completed. The ADMIN stated he could not guess what the potential negative outcome could be for the residents' care plans not reflecting an accurate code status, as he stated there are too many variables to consider. The ADMIN stated there was a reason the process exists to protect the residents and to promote the highest quality of care. The DON stated the final wishes of a resident could be missed if the care plans do not reflect an accurate code status for the residents. The DON stated there were a lot of variables, but the care plan wishes of the residents could be missed if their care plans were not accurate. Record review of the facility policy, Care Plans, Comprehensive Person-Centered, Revised [DATE], revealed the following documentation: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 7. The comprehensive, person-centered care plan: e. Reflects currently recognized standards of practice for problem areas and conditions. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 16 residents (Resident #27) reviewed for care plans. The facility failed to ensure Resident #27's care plan reflected the resident's current code status. This failure could place residents at risk of not receiving appropriate care to meet their current needs. Findings include: Resident # 27: Record review of a facility face sheet for Resident #27 dated [DATE] indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included the following: personality disorder (mental health condition where people have a lifelong pattern of seeing themselves and reacting to others in ways that cause problems), anemia (not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), anodontia (complete absence of teeth), muscle weakness-unspecified (lack of muscle strength), underweight, and other reduced mobility. Record review of Resident #27's Quarterly MDS (Minimum Data Set assessment) assessment dated [DATE], revealed under Section C Cognitive Patterns, a BIMS score of 11 indicating the resident was moderately cognitively impaired. Record review of physician orders dated [DATE] for Resident #27 indicated a Code Status of DNR. Record review of Resident #27's Out of Hospital Do Not Resuscitate (OOH-DNR) form dated [DATE] revealed it was completed by a qualified relative, signed by a physician, and signed by two witnesses. Record review of Resident #27's care plan dated [DATE] with a revision date of [DATE] revealed a care plan focus of Full Code with a goal that stated, residents wishes will be honored, and the intervention stated Resident wishes will be respected and acted upon. CPR will be performed if need arises. During an interview on [DATE] at 11:55 AM, the ADMIN and the DON stated ADON is responsible for ensuring care plans were completed and updated accurately. The ADMIN stated the ADON was not working on this day and was unavailable for interview. The ADMIN stated the ADON was the MDS nurse as well. The ADMIN stated the ADON was having trouble keeping up with the care plans. The ADMIN stated the contracted personnel were not located in the facility. The ADMIN stated Resident #27 had a code status of DNR. The DON confirmed this. The ADMIN and DON both stated they were unaware the care plan for Resident #27 indicated a code status of Full Code (medical directive that instructs a patient's healthcare team to perform all possible measures to save the patient's life in the event of a medical emergency). The ADMIN and the DON were unsure why Resident # 27's care plan did not reflect an accurate code status. The ADMIN stated the ADON should have received training on completing and updating care plans at some point, but he was unsure of when that occurred. The ADMIN stated the ADON received ongoing training on how to complete and update care plans and she should have known these updates were needed. The ADMIN stated updating care plans when changes occur was included in the facility's policy related to care plans. The ADMIN stated the facility had an MDS and care plan consultant that monitored the completion of care plans to help ensure they are completed and updated, but he was unsure why these updated were not completed. The ADMIN stated he could not guess what the potential negative outcome could be for the residents' care plans not reflecting an accurate code status, as he stated there are too many variables to consider. The ADMIN stated there was a reason the process exists to protect the residents and to promote the highest quality of care. The DON stated the final wishes of a resident could be missed if the care plans do not reflect an accurate code status for the residents. The DON stated there were a lot of variables, but the care plan wishes of the residents could be missed if their care plans were not accurate. Record review of the facility policy, Care Plans, Comprehensive Person-Centered, Revised [DATE], revealed the following documentation: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 7. The comprehensive, person-centered care plan: e. Reflects currently recognized standards of practice for problem areas and conditions. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment.

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 dining rooms reviewed for dietary services, in that: The facility failed to ensure foods were served under sanitary conditions. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made on 08/28/24 at 12:25 PM during observation of dining services: LVN A took a resident's tray and placed items on the table in front of the resident. LVN A picked up the bread roll with a bare hand and using a fork, separated the bread roll and applied butter. She placed the bread roll back on the resident's plate using a bare hand. During an interview on 08/28/24 at 01:40 PM with LVN A, she stated I did pick up resident's bread roll and used fork to separate roll to butter his roll. She stated she normally used the resident's fork and knife, but the resident does not have a knife because he likes to cut things. She stated she should have used a glove to pick up the residents' food. She stated, that is just me screwing up, plain and simple. She stated the potential negative outcome of touching food with bare hands could be making the resident sick. She stated she had been trained to not touch residents' food with bare hands. During an interview on 08/30/24 at 10:35 AM with the ADM, he stated food should not be touch by bare hands while serving to residents. He stated he is not sure who trains the staff. He stated the potential negative outcome was most of the time nothing going to happen, but food borne illness is a thing and that is why we take precautions. During an interview on 08/30/24 at 11:42 AM the DON she stated there is no new staff and all staff should be trained on food handling. She stated she is not sure who trains staff. She stated they were probably trained by the DON or DM. She stated food should never be touched with bare hands. She stated the potential negative outcome could be cross contamination and could make residents sick or cause death because our population is very elderly. Record review of the facility policy, titled General Food Preparation and Handling, dated 2010, revealed the following: Policy: Food items will be prepared to conserve maximum nutritive value, develop, and enhance flavor and free of injurious organisms and substances. Procedure: . 3. h. Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact of prepared foods .

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly for 1 of 2 medication carts (medication cart for hall 100-200) in that: 1. The medication cart assigned to hall 100-200 contained expired medications. This failure could place residents at risk of not receiving prescribed medications as ordered, receiving medications that are less effective or have altered composition, and drug diversions. The findings included: Observation on 08/28/24 at 01:20 PM of the medication cart for hall 100-200 with LVN B, reflected expired medications were found on the cart. Medications included: Lactulose liquid 10 G/15 ml with an expiration date of 05/24, Senna Plus with an expiration date of 06/24, and Melatonin 1 mg with an illegible manufacturer's expiration date and a date of 07/24 hand-written on the bottle. Expired dates for Lactulose liquid and Senna Plus were verified with LVN B. The expiration date on the Melatonin bottle could not be determined by LVN B. These medications were removed from the cart for destruction by LVN B. During an interview on 08/28/24 at 01:24 PM with LVN B, she stated she was not sure why there were expired medications on the cart. She stated it was the responsibility of the charge nurses to check the carts for expired medications and remove any expired medications for destruction. She stated the medication carts were usually checked weekly for expired medications. LVN B stated she had been trained on proper medication storage through in-services conducted at the facility. During an interview on 08/30/24 at 11:14 AM with the DON, she stated nursing staff and medication aides were responsible for checking medication carts for expired medications. The DON stated she had conducted staff training quarterly and as needed on proper medication storage, including assuring all medications were within the manufacturer's date. The DON stated it was her expectation that staff follow policy and procedure for compliance and the best possible outcome for residents. She stated a potential negative outcome for failure to remove expired medications from the cart would be that residents could get sick or be harmed from being administered an expired medication. During an interview on 08/30/24 at 11:32 AM with the ADM, he stated medication aides, charge nurses and nursing administration were responsible for checking medication carts for expired medications. He stated nursing administration was responsible to conduct staff training on proper medication storage. The ADM stated it was his expectation that staff check medication dates prior to administering medications and that there should be a systemic process to assure proper medication storage. He stated he could not give a potential negative outcome for a resident being given an expired medication because he was not medically trained. He stated there was a reason for expiration dates on medications and the administration of medications should be done for the good of the resident. Record review of facility provided policy labeled, Medication Labeling and Storage, dated 2001, revealed: Policy Statement: The facility stores all medication and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Policy Interpretation and Implementation: Medication Storage 1. Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Medication Labeling 4. For over the counter (OTC) medications in bulk containers (if permitted by state law) the label contains: a. the medication name; b. strength; c. quantity; d. accessory instructions; e. lot number; and f. expiration date (if applicable).

Based on interviews and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of controlled medications for 2 of 6 residents (Residents #1 and #2) reviewed for pharmaceutical services. The facility failed to ensure that the MA accurately documented the narcotic count sheet for Resident #1's scheduled pain medication administration for Norco 5-325 mg. The facility failed to ensure the MA followed the physician's orders for Resident #1's scheduled pain medication administration for Norco 5-325 mg. The facility failed to ensure that LVN B documented the narcotic count sheet for Resident #2's scheduled pain medication for Norco 7.5-325mg. These failures could place residents at risk of having their medications diverted or missing. Findings included: Record Review of Resident #1's face sheet, dated 8/5/24 revealed Resident was a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: dementia (memory loss), muscle weakness, depression, insomnia, hypertension (high blood pressure), osteoarthritis, and pain in unspecified joint. Record review of Resident #1's MDS, dated [DATE] revealed a BIMS score of 8 that indicated Resident #1 had moderately impaired cognition. Record Review of Resident #1's care plan, revised date 4/24/24, revealed the following focus areas: Limited physical mobility related to pain, osteoarthritis, and pain medication therapy with medication-Hydrocodone/Acetaminophen. Interventions included administer medications as ordered by the physician, monitor/document side effects, and effectiveness. Record Review of Resident #1's Physician order, dated 6/5/24 revealed a medication order of Norco Oral Tablet 5-325 mg (Hydrocodone-Acetaminophen), give 1 tablet by mouth every 8 hours related to pain in unspecified joint, unspecified osteoarthritis. Record Review of Resident #1's Individual Patient Narcotic Record for Hydroco/APAP 5/325mg, documented that on 8/4/24 at 0500 AM LVN A signed out 1 tab for Resident #1 leaving a count of 104. The next entry signed by MA on 8/4/24 revealed that MA signed out 1 tab and entered a count of 103. The time entry of 6:00 a.m. had been written over and was not legible to determine if it was changed to 1200 p.m. or 2 p.m. The next entry revealed no time or date signed by MA with the words correct count of 102 initialed by LVN A. Record Review of Resident #1's Medication Administration Record (MAR) revealed, Medication: Norco Oral tablet 5-325mg (Hydrocodone-Acetaminophen) Give 1 tab by mouth every 8 hours related to pain in unspecified joint, unspecified osteoarthritis, start date 6/5/24: On 8/4/24 at 5:00 a.m. the medication was administered by LVN A, on 8/4/24 at 2:00 p.m. the medication was administered by the MA. No documented entry for 8/4/24 at 6:00 a.m. by MA. Record Review of Resident #1's progress notes, dated 8/4/24 at 6:28 p.m. by LVN A revealed: Upon SN arrival to work, SN was informed by med aid that after this SN gave resident her routine Norco 5-325 mg @ 0500 [5 am], med aid informed SN that she had accidentally gave resident another dose @ 0600 [6 am], DON made aware. Resident displays no adverse reactions without resp distress noted VS 136/74 78 18 97.6 96 RA. Record Review of Resident #2's face sheet, dated 8/5/24 revealed Resident was a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Heart failure, other chronic pain, pain in right shoulder, gout, osteoarthritis, generalized anxiety disorder, and major depressive disorder. Record Review of Resident #2's MDS dated [DATE] revealed a BIMS score of 15 that indicated intact cognition. Record Review of Resident #2's care plan, revised date 4/29/24 revealed the following focus areas: Arthritis of the lower back and hands, chronic pain related to age and arthritis, frequent gout glare ups, and receives medication for pain control. Interventions included give gabapentin, Norco, allopurinol, and Tylenol as ordered by the physician. Monitor and document for side effects and effectiveness. Record Review of Resident #2's physician order, dated 7/24/23 revealed a medication order of Norco Oral Tablet 7.5 325 mg (Hydrocodone-Acetaminophen), give 1 tablet by mouth four times a day related to other chronic pain. Record Review of the Individual Patient Narcotic Record for Resident #2 Hydroco/APAP 7.5/325mg, revealed that the last documented dose of 1 tab was logged by LVN B on 8/5/24 at 6:35 a.m. with a remaining count of 56. Record Review of Resident #2's Medication Administration Record (MAR) revealed, that LVN B administered Norco to Resident #2 on 8/5/24 at 7:00 am and at 12:00 p.m. During an interview on 8/5/24 at 10:15 a.m. Resident #1 stated that she received her medications and had no issues regarding medications. During an interview on 8/5/24 at 1:51 p.m. the DON stated that on 8/4/24 the MA gave Resident #1 a dose of Norco 5-325 at an unknown time. The DON stated that the MA documented the 2 p.m. dose into the MAR but did not document it on the narcotic count sheet. The DON stated that due to the MA's errors there were 2 medication errors. The DON stated that both LVN A and MA were not currently in the building. The DON stated she would provide phone numbers for LVN A and the MA. During a controlled medication count for medication cart 1 on 8/5/24 at 2:15 p.m. with LVB B revealed that Resident #2's Individual Patient Narcotic Record for Hydroco/APAP 7.5/325mg, documented a remaining count of 56. Resident #2's medication card for Hydroco/APAP 7.5/325mg revealed a count of 55 remaining pills. During an interview on 8/5/24 at 2:27 p.m. LVN B stated that she did not log Resident #2's Hydrocodone on controlled substance/narcotic count sheet when she administered it at 1:00 p.m. on 8/5/24. LVN B stated that the count was off on the sheet. LVN B stated that she had been trained on medication administration and to verify the right resident, right route, date of birth, log it out of the narcotic book, and log into the MAR. LVN B stated I couldn't tell you why I didn't log that one. I guess I got into a hurry. LVN B stated that she would have found the error when she went to administer the 3 p.m. dose to Resident #2. LVN B stated that it was important to log it on the narcotic sheet because the next staff member would had thought that Resident #2 did not receive the dose and could have given Resident #2 an extra dose. LVN B stated that she did log it on the MAR. LVN B stated that if a resident received an extra dose it could result in the resident feely drowsy, falls, or confusion. LVN B stated that at shift change the nurses or medication aids count the narcotics to verify the count. LVN B stated if the count was off in the book, staff would conduct another count, and notify the DON. LVN B stated that staff were not permitted to leave the building until the DON conducted her investigation. During an interview on 8/5/24 at 2:40 p.m. with the DON and LVN B; the DON stated that LVN B did not have the controlled substance logbook when she administered the medication to Resident #2 because she (the DON) had the book at the time. The DON stated that LVN B should not have administered the medication to Resident #2 because LVN B could not verify the count and could not log that she removed a pill from the cart for Resident #2. The DON stated that although LVN B documented that she administered the pain medication to Resident #2 in the MAR, she did not follow policy and procedure because she did not have the controlled substance logbook. During an interview on 8/5/24 at 3:01 p.m. Resident #2 stated that her Norco pain medication was scheduled throughout the day, and she has never missed a dose. Resident #2 stated she received her dose this afternoon after lunch and had no issues with pain medication or receiving her medications. During an interview on 8/5/24 at 3:40 p.m. the DON stated that when an additional dose of Norco was administered to a resident there was always a risk that a resident could have complications such as death, respiratory failure, fatigue, or falls. The DON stated that Resident #1 was only on a 5-325mg dose of Norco which was not enough to cause death or respiratory failure. The DON stated that the MA should had immediately notified her that she gave Resident #1 an additional dose of Norco one hour after LVN A did. The DON stated that if she had been notified, the physician would have been immediately notified, and Resident #1 would had been monitored for signs and/or symptoms in addition to monitoring of her vital signs. The DON stated that LVN B could have forgotten that she gave the dose when she failed to log it on the count sheet and could have given another dose due to her not logging it on the count sheet. The DON stated that none of these people are new and that the MA was an agency medication aid before she was hired by the facility. The DON stated that both LVN B and the MA know how to properly administer and log medications in the MAR and on the controlled substance logs. The DON stated that there was no excuse for the MA not reporting to the nurse or to her that she had given Resident #1 an additional dose. During a phone interview on 8/6/24 at 7:00 am, MA stated, I gave [Resident #1] an extra dose of her Norco on 8/4/24 at 6a.m. I did not look at the MAR in the computer. I did not inform anyone that I gave the extra dose until we did the med count at 6pm. I had been trained on how to properly give medications, to check the MAR first before pulling the medication from the cart, verifying the correct count, and logging the dose into the MAR and count sheet. I just didn't do that. What are you trying to accuse me of? I didn't look at the computer to check first. That was my bad. Due to the MA becoming defensive during the interview, this INV thanked MA for her time and MA terminated the call. During a phone interview on 8/6/24 at 10:00 LVN A stated that they work the 6 p.m. to 6 a.m. shift. LVN A stated that on 8/4/24 they gave Resident #1 a dose of Norco at 5 a.m. LVN A stated when they returned to the 6 p.m. shift on 8/4/24, Resident #1's count sheet for Norco 5/325mg was off one pill. LVN A stated that the MA stated that she accidently gave Resident #1 another dose on 8/4/24 at 6 a.m. and it was documented on the count sheet. LVN A stated that on that entry by the MA, the count was correct, but the MA did not document that the 2 p.m. dose was given on the count sheet. LVN A stated that the DON was notified that the count was off and advised them to do a correct count. LVN A stated that another entry was written by MA correcting the count to match the number of pills remaining and LVN A stated they initialed it. LVN A stated that all staff who administer medications were trained to document on the controlled count sheet and to enter the medication administration in the MAR. LVN A stated that by the MA not documenting that she administered the extra dose to Resident #1, it could have caused adverse effects cause Resident #1 to be drowsy or staff to possibly give the next dose. During a phone interview on 8/9/24 at 9:52 a.m. LVN C stated that she worked on 8/4/24 from 6 a.m. to 6 p.m. and was not notified by the MA that the MA gave Resident #1 an extra dose of Norco 5/325mg an hour after LVN A administered it. LVN C stated that at the end of the shift during a count of the narcotics it was revealed that a pill was missing from Resident #1's Norco packet and was not logged on the control count sheet. LVN C stated that the MA stated that she gave Resident #1 a dose at 6 a.m. in error. LVN C stated that had the MA checked the MAR, it would have indicated that Resident #1 received the dose by LVN A. LVN C stated that staff were trained how to properly administer medications, to check the count sheet and pills left to verify they match, and to document administration in the MAR. LVN C stated that the MA should not have administered the extra dose to Resident #1 because Resident #1 could have been lethargic, had lowered blood pressure or a fall. Record Review of facility provided policy, Administering Medications, dated April 2019 revealed in part: Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. 1. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. 2. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 3. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 4. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered. b. the dosage. c. the route of administration. d. the injection site (if applicable). e. any complaints or symptoms for which the drug was administered. f. any results achieved and when those results were observed; and g. the signature and title of the person administering the drug. Record Review of the facility provided policy, Controlled Substances, revised December 2012, revealed in part: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of Schedule II and other controlled substances. Nursing staff must count controlled medications at the end of each shift. The nursing coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services.

Based on interviews and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 6 residents (Resident #1) reviewed for medication administration. The facility failed to ensure the MA followed the physician's orders for Resident #1's scheduled pain medication administration for Norco 5-325 mg when she administered a dose one hour after Resident #1 received the previous dose. This failure could place residents at risk of receiving incorrect amounts of medication prescribed by their physician. Findings included: Record Review of Resident #1's face sheet, dated 8/5/24 revealed; Resident # is a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Dementia (memory loss), Muscle weakness, Depression, Insomnia, Hypertension (high blood pressure), Osteoarthritis, and pain in unspecified joint. Record Review of Resident #1's care plan, revised date 4/24/24, revealed the following focus areas: Limited physical mobility related to pain, Osteoarthritis and pain medication therapy with medication-Hydrocodone/Acetaminophen. Interventions include Administer medications as ordered by physician, monitor/document side effects and effectiveness. Record review of Resident #1's MDS, dated [DATE] revealed a BIMS score of 8 that indicated Resident #1 has moderately impaired cognition. Record Review of Resident #1's Physician order, dated 6/5/24 revealed a medication order of Norco Oral Tablet 5-325 mg (Hydrocodone-Acetaminophen), give 1 tablet by mouth every 8 hours related to pain in unspecified joint, unspecified osteoarthritis. Record Review of Resident #1's Individual Patient Narcotic Record for Hydroco/APAP 5/325mg, documented that on 8/4/24 at 5:00 a.m. LVN A signed out 1 tab for Resident #1 leaving a count of 104. The next entry signed by MA on 8/4/24 revealed that MA signed out 1 tab and entered a count of 103. The time entry of 6:00 a.m. had been written over and was not legible to determine if it was changed to 1200 p.m. or 2:00 p.m. The next entry revealed no time or date signed by MA with the words correct count of 102 initialed by LVN A. Record Review of Resident #1's Medication Administration Record (MAR) revealed, Medication: Norco Oral tablet 5-325mg (Hydrocodone-Acetaminophen) Give 1 tab by mouth every 8 hours related to Pain in unspecified joint, unspecified osteoarthritis, start date 6/5/24: 8/4/24 5:00 a.m. administered by LVN A, 8/4/24 2:00 p.m. administered by MA. No documented entry for 8/4/24 at 6:00 a.m. by MA. Record Review of Resident #1's progress notes, dated 8/4/24 at 6:28 p.m. by LVN A revealed: Upon SN arrival to work, SN was informed by med aid that after this SN gave resident her routine Norco 5-325 mg @ 0500 [5 am], Med aid informed SN that she had accidentally gave resident another dose @ 0600 [6 am], DON made aware. Resident displays no adverse reactions without resp distress noted VS 136/74 78 18 97.6 96 RA. During an interview on 8/5/24 at 10:15 a.m. with Resident #1; Resident #1 stated that she received her medications and had no issues regarding medications. During an interview on 8/5/24 at 1:51 p.m. with the DON; stated that on 8/4/24 the MA gave Resident #1 a dose of Norco 5-325 mg one hour after LVN A gave Resident #1 the scheduled dose. The DON stated that it was not documented into the MAR and the MA did not notify any staff that she gave the extra dose. The DON stated that the MA documented the 2 p.m. dose into the MAR but did not document it on the narcotic count sheet. During an interview on 8/5/24 at 3:40 p.m. with the DON, the DON stated that when an additional dose of Norco is administered to a resident there is always a risk that a resident could have complications such as death, respiratory failure, fatigue or falls. The DON stated that Resident #1 was only on a 5-325mg dose of Norco which was not enough to cause death or respiratory failure. The DON stated that the MA should had immediately notified her that she gave Resident #1 an additional dose of Norco one hour after LVN A did. The DON stated that if she had been notified, the physician would have been immediately notified and Resident #1 would had been monitored for signs and/or symptoms in addition to monitoring of her vital signs. The DON stated that none of these people are new and that the MA was an agency medication aid before she was hired by the facility. The DON stated that the MA knew how to properly administer and log medications in the MAR and on the controlled substance logs. The DON stated that there was no excuse for the MA not reporting to the nurse or to her that she had given Resident #1 an additional dose. During a phone interview on 8/6/24 at 7:00 am, MA stated, I gave [Resident #1] an extra dose of her Norco on 8/4/24 at 6a.m. I did not look at the MAR in the computer. I did not inform anyone that I gave the extra dose until we did the med count at 6pm. I had been trained on how to properly give medications, to check the MAR first before pulling the medication from the cart, verifying the correct count, and logging the dose into the MAR and count sheet. I just didn't do that. What are you trying to accuse me of? I didn't look at the computer to check first. That was my bad. Due to the MA becoming defensive during the interview, this INV thanked CMA for her time and CMA terminated the call. During a phone interview on 8/6/24 at 10:00 with LVN A; stated that they work the 6 p.m. to 6 a.m. shift. LVN A stated that on 8/4/24 they gave Resident #1 a dose of Norco at 5 a.m. LVN A stated when they returned to the 6 p.m. shift on 8/4/24, Resident #1's count sheet for Norco 5/325mg was off one pill. LVN A stated that the MA stated that she accidently gave Resident #1 another dose on 8/4/24 at 6 a.m. and it was documented on the count sheet. LVN A stated that the MA did not document that the 2 p.m. dose was given on the count sheet. LVN A stated that the DON was notified that the count was off and advised them to do a correct count. LVN A stated that another entry was written by MA correcting the count to match the number of pills remaining and LVN A stated they initialed it. LVN A stated that all staff who administer medications are trained to document on the controlled count sheet and to enter the medication administration in the MAR. During a phone interview on 8/9/24 at 9:52 a.m. with LVN C, stated that she worked on 8/4/24 from 6 a.m. to 6 p.m. and was not notified by the MA that the MA gave Resident #1 an extra dose of Norco 5/325mg an hour after LVN A administered it. LVN C stated that at the end of the shift during a count of the narcotics it was revealed that a pill was missing from Resident #1's Norco's and was not logged on the control count sheet. LVN C stated that the MA stated that she gave Resident #1 a dose at 6 a.m. in error. LVN C stated that had the MA checked the MAR, it would have indicated that Resident #1 received the dose by LVN A. LVN C stated that staff are trained how to properly administer medications, to check the count sheet and pills left to verify they match and to document administration in the MAR. LVN C stated that the MA should not have administered the extra dose to Resident #1. Record Review of facility provided policy, Administering Medications, dated April 2019 revealed in part: Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. 6. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 7. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 8. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: h. the date and time the medication was administered. i. the dosage. j. the route of administration. k. the injection site (if applicable). l. any complaints or symptoms for which the drug was administered. m. any results achieved and when those results were observed; and n. the signature and title of the person administering the drug. Record Review of the facility provided policy, Controlled Substances, revised December 2012, revealed in part: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of Schedule II and other controlled substances. Nursing staff must count controlled medications at the end of each shift. The nursing coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained free of accident hazards for 3 of 3 residents (Resident #1, Resident #2 and Resident #3) reviewed for quality of care in that: CNA A failed to operate the Hoyer lift with 2 staff per facility policy when transferring Resident #1 from the wheelchair to the bed. As a result Resident #1 sustained a head injury and was sent to the hospital. Resident #2 stated that staff (unknown) lifted him majority of the time with 1 staff using the Hoyer lift. Uncertified Nurses aides (NA B and NA C) admitted to using the Hoyer lift to transfer residents. The Director of Nurses (DON) and the Director of Rehabilitation (DOR) did not ensure that staff were trained according to their lifting policy to use the Hoyer. The DOR and DON did not have a contingency plan in place if the only Hoyer lift was not operational. A confidential staff admitted to utilizing the Hoyer lift with one staff to transfer residents. The Agency Nurse failed to assess/ take vitals of Resident #1 after she sustained a head injury after being dropped out of the Hoyer lift on [DATE]. Observation of staff (CNA E, F, H & J) using the Hoyer lift to transfer residents (Resident# 1 and Resident #3) revealed that they did not inspect the Hoyer sling and lock the wheels during the process. On [DATE] at 5:12 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] at 3:50 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern 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 or injury and contribute to avoidable accidents. Findings Included: Resident 01 Record review of Resident #01's face sheet, dated [DATE], revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia and need for assistance with personal care. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #01 usually understood (misses some part/intent of message but comprehends most conversations). The MDS revealed Resident #01 had a BIMS of 00 which indicated the resident's cognition was severely impaired. Section G revealed the resident transfer required (total dependence) with support (two+ person physical assist) Record review of a care plan, dated [DATE] for Resident #01 revealed: Focus: May use Hoyer lift as needed for transfers; Goal: Will have safe transfers through the review date; Interventions: Assisted transfers with 2 licensed staff. Record review of a care plan, dated [DATE] for Resident #01 revealed: Focus: This resident had a fall from the mechanical lift on [DATE] with a laceration to the back of the head r/t improper use of the mechanical lift by staff; The resident's laceration will be healed by the review date without complications; Interventions: Staff training for proper mechanical lift training. Record review of a care plan, dated [DATE] for Resident #01 revealed: Focus: The resident has an ADL self-care performance deficit r/t dementia, impaired balance, limited mobility, stroke; Goal: The resident will maintain current level of function in mobility and ADLs through the review date; Interventions: Transfer: the resident requires total assistance by 2 staff & Hoyer lift to move between surfaces. Record review of hospital records dated [DATE] revealed the following: [AGE] years female, trauma-dropped out of Hoyer lift Findings: Brain: Small acute left subdural hematoma measuring up to 5 mm in greatest transverse diameter. No abnormal right sided extra-axial fluid collections. Discharge Diagnosis: Fall, laceration of right side of scalp, subdural hematoma Record review of the transfer paperwork titled, SNF/NF to Hospital Transform Form, undated, revealed the following: Vital signs (blood pressure, heart rate, respiration rate, oxygen level) data dated 5 days before the incident ([DATE]) The pain level data dated 2 days before the incident ([DATE]) Form completed and reviewed by On Call Charge Nurse dated [DATE] at 7:20 PM. Resident 02 Record review of Resident #02's face sheet, dated [DATE], revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include dementia, difficulty walking, unsteadiness on feet, need for assistance with personal care and personal injury of traumatic brain injury. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #02 was usually understood (misses some part/intent of message but comprehends most conversation). The MDS revealed Resident #02 had a BIMS of 07 which indicated the resident's cognition was severely impaired. Section G revealed the resident transfer required (Extensive Assistance) with support (two+ person physical assist) Record review of a care plan, dated [DATE] for Resident #02 revealed the following: Focus: The resident has an ADL self care performance deficit r/t history of traumatic brain injury, dementia, cognitive and low vision; Goal: The resident will maintain current level of function through the review date. Staff will meet his needs; Transfer: The resident requires limited to extensive assistance by ,d+[DATE] staff to move between surfaces as necessary. Resident 03 Record review of Resident #03's face sheet, dated [DATE], revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia and a history of falling. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #03 was rarely understood. The MDS revealed Resident #03 had a BIMS of 00 which indicated the resident's cognition was severely impaired. Section G revealed the resident transfer required (total dependence) with support (two+ person physical assist) Record review of a care plan, dated [DATE] for Resident #03 revealed: Focus: The resident has an ADL self care performance deficit; Goal: The resident will maintain current level of function through the review date; Interventions: The resident requires total dependence by Hoyer lift to move between surfaces. During an interview on [DATE] at 3:16 PM, CNA A stated Resident #1's roommate needed to go to the restroom. She said since Resident #1's roommate was on the toilet and was by herself, she moved the bed diagonally to observe both residents. She said she had the Hoyer, opened the legs, and slid the lift under Resident #1's wheelchair. She said she hooked the sling onto the Hoyer lift. She said she had checked everything. She said she remembered that she had the top strap on the blue loop, the middle strap on the green, and the bottom straps crossed on the green loop. She said she lifted the resident up to get tension on the straps. She said she guided her safely to the bed. She said she heard a loud pop once she was over the bed. She said she saw Resident #1 hit her head on the headboard. She said she pushed the call light for help. She said she yelled for help. She said she left the resident, but not for long. She said she knew she was not supposed to leave the resident, but she went and got the nurse in charge. She said she was an agency nurse. She said she stayed with Resident #1 after she got the nurse. She said she placed a cold towel on Resident #1 head. She said she did not remember if the nurse took her vitals. She said the other CNA on shift that night was putting her residents down. She said they tried to put their residents at risk for falls down first. She said she would never transfer another resident with the Hoyer alone again. She said this was her first time doing this alone. She said she had been trained when she first started at the facility, but it had been a while. She said she has been at the facility for over a year. She said she has never had to demonstrate her ability to use the Hoyer lift. She said she had signed an in-service. During an interview on [DATE] at 10:45 AM, the Agency Nurse stated she arrived at work at 5:30 PM. She said around 6:30 PM was when the incident with Resident #1. She said CNA A came to her flabbergasted, as something bad had happened. She said that CNA A kept saying, It was an accident, and I did not mean for it to happen. The Agency Nurse said she was in the medication room and was unsure what she would need. She said she gathered gauze and wound cleanser. She said she went to Resident #1s room, and she was laid on her left side. She said Resident #1 was awake. She said CNA A had placed a damp towel on Resident #1 head. She said when she removed the towel, there was a mass of blood mixed in with Resident #1's hair. She said the bleeding stopped, and you could see the laceration. She said CNA A told her that she was transferring Resident #1 from the wheelchair to the bed with the Hoyer by herself, and the strap came loose. The Agency Nurse said she told CNA A that she was not supposed to operate the Hoyer by herself. She said CNA A said she knew she was not supposed to. She said she did not know who she was supposed to call or what the emergency procedure was for the facility. She said she called the on-call charge nurse, and she said she was in the facility. She said she went to the on-call nurse's office. She said the on-call nurse told her to call the nurse practitioner and then gave her the number for the sheriff's department. She said she was told to call the sheriff's department because EMS responds quicker. She said she called the NP at 6:40 PM. She said she called the sheriff's office at 6:42 PM. She said she called the ADM at 6:50 PM. She said the on-call charge nurse would contact the DON. She said she notified Resident #1s family member at 6:53 PM. She said EMS arrived at 7:00 PM. She said the on-call charge nurse helped her get the paperwork to give to the EMS. She said EMS left with the resident around 7:05 PM. She said she forgot to call the hospital and give a report verbally. She said she did not get Resident #1's vitals. She said she was so frantic she did think to do them. She said she was focused on getting Resident #1 out of the facility. She said the purpose of taking vital signs was to get a baseline. She said it was good because neuro checks are also done. Neurological checks could let one know if something was happening in the brain. She said she was not aware that old vital signs were submitted. She said the on-call charge nurse was the person who submitted the vitals. She said she printed off the face sheet and the medication administration record. She said not taking vitals could have caused staff to miss if something was severely wrong. She said vitals could have helped identify the resident's diagnosis (subdural hematoma). She said she could have looked at the resident pupils. She had a subdural hematoma, which was a serious diagnosis. She said it was a pocket of blood outside of the brain but not outside of the skull. She said she had not been oriented to the facility or their processes as an agency nurse. She said she did not receive a tour of the facility and was not oriented to any policies or what to do in an emergency according to the facility policy. During an interview on [DATE] at 11:11 AM, the On Call Charge Nurse stated she was working in her office when she received the call from the Agency Nurse. She said she told her to come to her office. She said CNA A was crying. She said CNA A told her she was putting Resident #1 in bed. She said she heard a popping noise when she pushed the Hoyer down. She said CNA A said the strap popped off. She said once she knew the resident was safe, she had CNA A write a statement and then ask her to leave. She said she had given The Agency nurse a list of things to do. She said she was not sure if the Agency nurse was frantic. She said she gave her the NP and sheriff's department numbers. She also said on the list she had that she needed to put the information in the computer about the incident and notify the family. She said she told The Agency Nurse to update the vitals. She said she did not notice that the vitals were not current until she later found out that the Agency nurse did not give report to the hospital. She said she was at the facility until 2:30 AM on [DATE] & [DATE]. She said Resident #1 was sent to the hospital and was diagnosed with a subdural hematoma. She said a subdural hematoma was a bleed on the brain, and if it continues to bleed, it can lead to death. She said the purpose of taking a resident vitals after a fall was to identify shock, stability, and a baseline for the residents. She said a person's pulse and neurological checks could have identified if there was a bleed on the brain. She said if there was any indication of neurological problems, then EMS would need to know this because that would change how they treat Resident #1. She said the EMS took time to clean the resident up, but if there was knowledge of potential head trauma or vitals that were abnormal, they would have been busy driving getting her to the hospital. She said she did orient the Agency Nurse to the facility procedures two days prior. She said she asked the Agency Nurse and said she did not have any questions. She said all nurses should know what to do in an emergency. She said the Agency Nurse was responsible for getting Resident #1 vitals. During an interview on [DATE] at 8:04 AM, the Hospital Nurse stated a subdural hematoma was a serious diagnosis. She said it was bleeding in the brain. She said a person could die from that diagnosis. She said she had worked with Resident #1 during her hospital visit on [DATE]. She said that Resident #1 came back in on ,d+[DATE] for fever and tachycardia (fast heartbeat). She said this diagnosis could be related to her fall on [DATE]. She said her brain may not be regulating properly with the Dx of subdural hematoma. For example, her brain may not properly tell her how to swallow. She said the hospital did have Hoyer lifts, and they use them. She said it should always be two staff. She said the fact they need a Hoyer indicates that it is a lift that cannot be done alone. She said the second person was vital because that ensures the sling is properly placed under the resident, helps with a safe transfer, and has someone there if anything happens. She said not having vitals could aggravate hospital staff because they cannot see the resident's progression or decline. She said it is common nursing sense to obtain vitals and neurological checks. She said having vitals from 5 days before ([DATE]) would not likely be the same at [DATE], especially if she had bleeding in her brain. During an interview on [DATE] at 2:04 PM, Resident #1 could not answer any questions regarding the incident on [DATE] and about past transfers with the Hoyer lift. During an interview on [DATE] at 10:30 AM, the ADM stated CNA A went to place Resident #1 to bed, and she required the Hoyer lift. CNA A went by herself without the second CNA. She said she was told by CNA A that one of the straps was not secure and came off. Resident #1 hit her head on the headboard. She said it caused a laceration to the back of the head. She said the strap did not break; it just came loose. She said she was unsure why CNA A did not have the 2nd CNA for help. She said CNA A told the charge nurse she knew better than using the Hoyer alone. She said this incident occurred Saturday ([DATE]) around 7:00 PM. She said she sent CNA A home around 7:15 PM. Record review of a care plan, dated [DATE] for Resident #01 revealed: Focus: This resident had a fall from the mechanical lift on [DATE] with a laceration to the back of the head r/t improper use of the mechanical lift by staff; The resident's laceration will be healed by the review date without complications; Interventions: Staff training for proper mechanical lift training. During an interview on [DATE] at 10:35 AM, the ADON stated the expectation of the use of the Hoyer was that it had to be 2 certified nurse aides. She said it could not be a nurse aide. She said the CNA A was certified. During a confidential interview, it was revealed that they (unidentified staff) used the Hoyer alone when short-staffed. They said they were often short-staffed when they came in. They said they recently used the Hoyer lift alone. They said they used the Hoyer last week to transfer a resident. They said they were not the only ones to use the Hoyer alone but that other staff members also used the Hoyer lift with one staff. They said that they had never received Hoyer training at the facility. They said they had never had to demonstrate their knowledge of the Hoyer to anyone. They said they did not know the facility staff oriented agency staff to policy and procedures. They said that they have observed agency staff come in and have to ask questions constantly to provide care to the residents. They said they were relieved that what happened to CNA A and Resident #1 did not happen to them because it could have. During an interview on [DATE] at 1:10 PM, NA B stated she had been an NA for 2 weeks. She said she had used the Hoyer lift with another certified CNA. She said she rolled the resident and paced the net under them. She said they then hooked them up to the Hoyer. She said she had never used the Hoyer alone. She said she had not had recent training from the facility. During an interview on [DATE] at 1:18 PM, NA C stated that she had used the Hoyer lift with the assistance of a certified CNA. She said they had placed a resident in bed and left the sling under them in case they needed to be changed. She said she had not had any formal training. During an interview on [DATE] at 3:05 PM, the Director of Rehabilitation stated they had Hoyer lift training several months ago. He said it was an orientation for everyone. He said during the Hoyer lift training, they discussed the use of the Hoyer, transfers, and gait belts. He said they talked about how to place the sling under the resident. He said they trained the staff to use two people. He said he did not have staff demonstrate the use of the Hoyer. He said the staff present watched him. He said he was not familiar with CNA A. He said he had seen Resident #1 and said the Hoyer lift was an appropriate transfer method for Resident #1 because she could not bear weight. He said that the Hoyer sling used to transfer Resident #1 was not damaged that he knew of and the facility only had one Hoyer lift; if it went out, they did not have a contingency plan. He said if they did have a contingency plan this would help the resident. During an interview on [DATE] at 11:30 AM, CNA E stated she had not been checked off on the use of the Hoyer lift. She said she has never had to demonstrate her knowledge and ability to use the Hoyer lift. She said she has not been trained on a contingency plan in what to do if the one Hoyer they have was to stop working. She said she could use a sheet or get another staff to grab an arm and leg. She said the potential negative outcome of not having a contingency plan would be residents could get hurt. During an interview on [DATE] at 11:35 AM, CNA E stated that if Hoyer was not working, she would get the older one. She said they have a crank Hoyer that they can use. She said she does take vitals, but it was a nurse's duty. During an interview on [DATE] at 11:40 AM, CNA G stated she had been checked off to use the Hoyer lift. She said she has never had to demonstrate. She said if the Hoyer lift does not work, the facility has a manual Hoyer lift that they are supposed to use. She said she was agency staff and had never been oriented to the facility policy and procedures. She said she just used her prior knowledge. During an interview on [DATE] at 11:45 AM, CNA H stated she had training with a group while back at the facility but did not demonstrate it for competency. She said she was unaware of a contingency plan if the one Hoyer lift did not work. During an interview on [DATE] at 11:50 AM the DON stated improper use of the Hoyer lift can lead to serious injury even death. She said it could have been worse if CNA A had not been over the bed. She said not taking a resident's vitals after a fall would mean the staff do not know the status of the resident and they could be worse than what was physically seen. She said not having a contingency plan for the Hoyer could lead to the staff not having a way to transfer the resident. She said there was only one Hoyer because the older one had been decommissioned. She said the staff were no longer using the old Hoyer. She said she did not know where the Hoyer was. She said she was unaware that the staff had not demonstrated using the Hoyer. She said she knew that they went over how to use the Hoyer, but this was before she was hired. She said she was unaware that non-certified aides were using the Hoyer lift. She said she was unaware that there was staff using the Hoyer alone because of staffing. She said she was unaware that the Agency Nurse did not take the resident's vitals. She said she was also unaware that there was no formal contingency plan. Regarding systems in place to monitor the deficient practices, she said annual training should cover Hoyer's use. She said in her experience, she had to demonstrate her skills. She said regarding taking vitals, they have their accident policy. She said she did not have any additional support regarding a contingency plan to ensure things such as contingency plans were not missed. She said there was no system in place to monitor the staff using the Hoyer lift or taking vitals. She said she had to trust that they were doing their job. She said there was no documentation to support staff skill competency for the Hoyer lift. She said she had been trained on the use of the Hoyer when she worked at the hospital, but not at the facility. She said she had training regarding taking vitals after a resident had fallen. She said she had not received any training regarding a contingency plan. She said she expected staff to use the Hoyer with 2 staff. She said non-certified nurse aides should not use the Hoyer to transfer residents. She said they should not be a part of the 2 staff. She said non-certified nurse aides can observe. She said she expected the staff to be 100 percent trained and demonstrate their skills and use of the Hoyer. She said she expected agency staff to have all the skills and training before working in their facility. She expected additional staff to be used until they could secure a working lift. The DON did not specify what the staff would use to transfer. She said regarding Resident #1 and CNA A incident, she expected the CNA to use the Hoyer properly with two staff. She said she, as the DON, she was responsible for monitoring the use of the Hoyer lift. She said the policy said the ADON was responsible, but since she was over the ADON, it was her responsibility. She said orienting agency staff was the responsibility of the same disciplines. She said if it was a CNA, a facility CNA staff would orient the staff. She said if it was a nurse, then a facility nurse would orient the agency nurse. She said she and ADM were responsible for ensuring a contingency plan was in place for transferring residents if the one Hoyer they had was unavailable. She said vitals should have been done as a part of the assessments after a resident falls. She said she has seen staff use the Hoyer in the past but never watched CNA A. She said a subdural hematoma was a serious diagnosis. She said it was a bleed under the subdural tissue. She said it was serious, so she was kept overnight. She said it was very important to take vitals because they could miss something, and with this diagnosis, a resident could rapidly deteriorate. During an interview on [DATE] at 12:00 AM, the ADM stated not training and ensuring that the staff know how to use the Hoyer lift would mean that they, as management, do not know if the staff truly know how to use it. She said staff not properly being trained can lead to injury or death. She said regarding the resident #1 incident, she could have died . She said it could have been much worse if Resident #1 had not been over her bed. She said non-certified nurse aides are not trained, and they could also hurt someone. She said that by not orienting the agency staff to facility policies and procedures or emergency response, the agency staff may not know what they are doing. She said agency staff may do things in a way that was not acceptable to the facility. She said not having a contingency plan could result in the staff breaking something on the residents. She said she was unaware that there were no physical competencies and that the staff did not demonstrate the use of the Hoyer back. She said she was unaware that her non-certified nurse aides were using the lift. She said she was unaware that the Agency Nurse did not take resident vitals. Regarding agency staff, she said she had never had to orient the agency staff. She said they should know what they were doing regarding their skills. She said she was unaware there was no contingency plan for if the Hoyer lift was to no longer work. She said she was unaware that CNA A was using the Hoyer alone. She said she had no system to monitor staff training for Hoyer use and demonstration. She said she did not have a system to monitor if the uncertified nurse's aides were using the Hoyer lift because they were not supposed to use the Hoyer because they had not been fully trained. She said there was no system in place to orient the agency staff. She said there was a book with emergency numbers. She said there was no system to monitor contingency plans for the Hoyer lift. She said she was not sure where the old Hoyer lift was. She said the staff should not be using it. She said there was a sit-to-stand lift, but no one knew. She said she was unaware that CNA A had used the Hoyer by herself but believed if she had done it once she had done it more than once. She said she was unaware that other staff were using the Hoyer lift alone without a second staff. She said she had been trained in using the Hoyer and understood that staff should have demonstrated their use of the Hoyer. She said she has not personally been trained in taking vitals but understands that it has to be done after a fall. She said having a contingency plan had never been brought up. She said she expected all clinical staff to have been trained on using the Hoyer and should have physical competencies. She said she expected all staff to demonstrate to the Director of Rehab or the DON that they could properly use the Hoyer lift. She said it was not her expectation for staff to be just shown how to use the Hoyer. She said it was her expectation that the nurse in the facility take vitals after a fall. She said although she had seen CNAs take vitals, she had not seen them take them at her current facility. She said she understood that the CNA was trained to take vitals, but she did not want them taking vitals at the facility. She said the agency staff should know what comes with their respective discipline. The ADM stated For example, if they are a nurse, they should know all the skills and duties of a nurse. She said she expected if the agency staff had questions, they should ask them. She said with having one Hoyer lift, there should be a contingency plan in place to avoid injury and accidents. Regarding Resident #1 and CNA A, she expected the CNA to have retrieved another staff to help her and keep the resident safe from injury and accident. She said the DOR and the DON were responsible for completing physical competencies and ensuring that clinical staff demonstrated the use of the Hoyer per their policy and procedures. She said it was the responsibility of the DON and charge nurse to ensure that the uncertified nurse aides were not using the Hoyer lift and that other staff were not using the Hoyer lift alone. She said it was the responsibility of the charge nurse to ensure that vitals are taken after a resident falls or experiences any type of head trauma. She said not taking vitals after a potential head injury was unacceptable, especially with two nurses in the facility. She said the resident should not have been moved until assessed. She said overall, the DON was responsible for the activity of CNA A. The ADM confirmed that there were no records of physical competencies in the facility because they did not exist. She said Resident #1 Dx of subdural hematoma was serious because it was bleeding in the brain and Resident #1 could have bled out. She said taking vitals could have helped identify a serious issue with the resident neurologically. She said the staff may have had a chance to respond differently if vitals had been taken. During an observation that occurred on [DATE] at 1:37 PM CNA F and CNA I transferred Resident #3 from her wheelchair to the bed using the Hoyer lift. Prior to operation of the Hoyer neither staff inspected the sling to insure it was intact and safe for use. CNA F and CNA I did not lock the wheels of the Hoyer throughout the use of the Hoyer lift. During an observation that occurred on [DATE] at 1:52 PM CNA E and CNA J transferred Resident #1 from her wheelchair to her bed. Prior to operation of the Hoyer neither staff inspected the sling to insure it was intact and safe for use. Resident #1 was one sided in the sling and no adjustments was made to ensure that the sling was evenly under the resident. Neither staff locked the Hoyer lift prior to using it to lift the resident out of her wheelchair. During an interview on [DATE] at 8:04 AM, the Hospital Nurse stated a subdural hematoma was a serious diagnosis. She said it was bleeding in the brain. She said a person could die from that diagnosis. She said she had worked with the resident during her hospital visit on [DATE]. She said that Resident #1 came back in on ,d+[DATE] for fever and tachycardia (fast heartbeat). She said this diagnosis could be related to her fall on [DATE]. She said her brain may not be regulating properly with the Dx of subdural hematoma. For example, her brain may not properly tell her how to swallow. She said the hospital did have Hoyer lifts, and they use them. She said it should always be two staff. She said the fact they need a Hoyer indicates that it is a lift that cannot be done alone. She said the second person was vital because that ensures the sling is properly placed under the resident, helps with a safe transfer, and has someone there if anything happens. She said not having vitals could aggravate hospital staff because they cannot see the resident's progression or decline. She said it is common nursing sense to obtain vitals and neurological checks. She said having vitals from 5 days before ([DATE]) would not likely be the same at [DATE], especially if she had bleeding in her brain. During an interview on [DATE] at 8:15 AM, The Dispatcher stated they received their initial call at 6:41 PM. It was reported that they needed resident transport because of a head wound. She said at 6:51, the EMS workers were enroute and arrived at the facility. At 6:55 PM, they received a call from the EMS staff stating they needed to extend their time at the facility because the resident was not ready to pick up. At 7:23 PM, the EMS staff called in and said the resident was still not ready for pickup. She said she did not know why the resident was not ready. She said at 7:29, the EMS was enroute to the hospital. She said they arrived at the hospital at 7:50 PM. She said the medic on duty could give more information. During an interview on [DATE] at 8:27 AM, The Primary Care Physician stated he was not the doctor who was notified. He stated from the notes and his most recent dealings with Resident #1, he knew that The NP mainly took care of Resident #1, but he supervised her work. He said it was his understanding on [DATE] the staff at the facility lifted her with the Hoyer and dropped her. They spoke with NP, and she instructed the staff to send her to the ER. During that visit, she did have a laceration and a sub [TRUNCATED]

Based on interview and record review the facility failed to ensure licensed nurses and certified nurses Aides had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 3 of 3 Residents (Resident #1, #2, and #3) reviewed for nursing services. In that: The facility failed to ensure all clinical staff had physical competencies showing they were capable of utilizing the Hoyer lift. CNA A operated the Hoyer lift with on staff transferring Resident #1 which resulted in Resident #1 sustaining a head injury and being sent to the hospital. Uncertified Nurse Aides (NA B and C) admitted to operating the Hoyer lift to transfer residents. Resident #3 said that staff transfer him using the Hoyer lift with one staff. The Agency Nurse failed to assess/ take vitals of Resident #1 after she sustained a head injury after being dropped out of the Hoyer lift on [DATE]. Confidential Staff admitted to operating the Hoyer with one staff. Observation of staff (CNA E, F, H & J) using the Hoyer lift to transfer residents (Resident# 1 and Resident #3) revealed that they did not inspect the Hoyer sling and lock the wheels during the process. This failure could place all residents in need of transfer via the Hoyer lift at risk of injury, falls, hospitalization and death. Findings Included: Resident 01 Record review of Resident #01's face sheet, dated [DATE], revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia and need for assistance with personal care. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #01 usually understood (misses some part/intent of message but comprehends most conversations). The MDS revealed Resident #01 had a BIMS of 00 which indicated the resident's cognition was severely impaired. Section G revealed the resident transfer required (total dependence) with support (two+ person physical assist) Record review of a care plan, dated [DATE] for Resident #01 revealed: Focus: May use Hoyer lift as needed for transfers; Goal: Will have safe transfers through the review date; Interventions: Assisted transfers with 2 licensed staff. Record review of a care plan, dated [DATE] for Resident #01 revealed: Focus: This resident had a fall from the mechanical lift on [DATE] with a laceration to the back of the head r/t improper use of the mechanical lift by staff; The resident's laceration will be healed by the review date without complications; Interventions: Staff training for proper mechanical lift training. Record review of a care plan, dated [DATE] for Resident #01 revealed: Focus: The resident has an ADL self-care performance deficit r/t dementia, impaired balance, limited mobility, stroke; Goal: The resident will maintain current level of function in mobility and ADLs through the review date; Interventions: Transfer: the resident requires total assistance by 2 staff & Hoyer lift to move between surfaces. Record review of hospital records dated [DATE] revealed the following: [AGE] years female, trauma-dropped out of Hoyer lift Findings: Brain: Small acute left subdural hematoma measuring up to 5 mm in greatest transverse diameter. No abnormal right sided extra-axial fluid collections. Discharge Diagnosis: Fall, laceration of right side of scalp, subdural hematoma Record review of the transfer paperwork titled, SNF/NF to Hospital Transform Form, undated, revealed the following: Vital signs (blood pressure, heart rate, respiration rate, oxygen level) data dated 5 days before the incident ([DATE]) The pain level data dated 2 days before the incident ([DATE]) Form completed and reviewed by On Call Charge Nurse dated [DATE] at 7:20 PM. Resident 02 Record review of Resident #02's face sheet, dated [DATE], revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include dementia, difficulty walking, unsteadiness on feet, need for assistance with personal care and personal injury of traumatic brain injury. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #02 was usually understood (misses some part/intent of message but comprehends most conversation). The MDS revealed Resident #02 had a BIMS of 07 which indicated the resident's cognition was severely impaired. Section G revealed the resident transfer required (Extensive Assistance) with support (two+ person physical assist) Record review of a care plan, dated [DATE] for Resident #02 revealed the following: Focus: The resident has an ADL self care performance deficit r/t history of traumatic brain injury, dementia, cognitive and low vision; Goal: The resident will maintain current level of function through the review date. Staff will meet his needs; Transfer: The resident requires limited to extensive assistance by ,d+[DATE] staff to move between surfaces as necessary. Resident 03 Record review of Resident #03's face sheet, dated [DATE], revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia and a history of falling. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #03 was rarely understood. The MDS revealed Resident #03 had a BIMS of 00 which indicated the resident's cognition was severely impaired. Section G revealed the resident transfer required (total dependence) with support (two+ person physical assist) Record review of a care plan, dated [DATE] for Resident #03 revealed: Focus: The resident has an ADL self care performance deficit; Goal: The resident will maintain current level of function through the review date; Interventions: The resident requires total dependence by Hoyer lift to move between surfaces. During an interview on [DATE] at 10:30 AM, the ADM stated CNA A went to place Resident #1 to bed, and she required the Hoyer lift. CNA A went by herself without the second CNA. She said she was told by CNA A that one of the straps was not secure and came off. Resident #1 hit her head on the headboard. She said it caused a laceration to the back of the head. She said the strap did not break; it just came loose. She said she was unsure why CNA A did not have the 2nd CNA for help. She said CNA A told the charge nurse she knew better than using the Hoyer alone. She said this incident occurred Saturday ([DATE]) around 7:00 PM. She said she sent CNA A home around 7:15 PM. During an interview on [DATE] at 10:35 AM, the ADON stated the expectation of the use of the Hoyer was that it had to be 2 certified nurse aides. She said it could not be a nurse aide. She said the CAN A was certified. During a confidential interview, it was revealed that they (unidentified staff) used the Hoyer alone when short-staffed. They said they were often short-staffed when they came in. They said they recently used the Hoyer lift alone. They said they used the Hoyer last week to transfer a resident. They said they were not the only ones to use the Hoyer alone but that other staff members also used the Hoyer lift with one staff. They said that they had never received Hoyer training at the facility. They said they had never had to demonstrate their knowledge of the Hoyer to anyone. They said they did not know the facility staff oriented agency staff to policy and procedures. They said that they have observed agency staff come in and have to ask questions constantly to provide care to the residents. They said they were relieved that what happened to CNA A and Resident #1 did not happen to them because it could have. During an interview on [DATE] at 1:10 PM, NA B stated she had been an NA for 2 weeks. She said she had used the Hoyer lift with another certified CNA. She said she rolled the resident and paced the net under them. She said they then hooked them up to the Hoyer. She said she had never used the Hoyer alone. She said she had not had recent training from the facility. During an interview on [DATE] at 1:18 PM, NA C stated that she had used the Hoyer lift with the assistance of a certified CNA. She said they had placed a resident in bed and left the sling under them in case they needed to be changed. She said she had not had any formal training. During an interview on [DATE] at 3:05 PM, the Director of Rehabilitation stated they had Hoyer lift training several months ago. He said it was an orientation for everyone. He said during the Hoyer lift training, they discussed the use of the Hoyer, transfers, and gait belts. He said they talked about how to place the sling under the resident. He said they trained the staff to use two people. He said he did not have staff demonstrate the use of the Hoyer. He said the staff present watched him. He said he was not familiar with CNA A. He said he had seen Resident #1 and said the Hoyer lift was an appropriate transfer method for Resident #1 because she could not bear weight. He said that the Hoyer sling used to transfer Resident #1 was not damaged that he knew of and the facility only had one Hoyer lift; if it went out, they did not have a contingency plan. He said if they did have a contingency plan this would help the resident. During an interview on [DATE] at 3:16 PM, CNA A stated Resident #1's roommate needed to go to the restroom. She said since Resident #1's roommate was on the toilet and was by herself, she moved the bed diagonally to observe both residents. She said she had the Hoyer, opened the legs, and slid the lift under Resident #1's wheelchair. She said she hooked the sling onto the Hoyer lift. She said she had checked everything. She said she remembered that she had the top strap on the blue loop, the middle strap on the green, and the bottom straps crossed on the green loop. She said she lifted the resident up to get tension on the straps. She said she guided her safely to the bed. She said she heard a loud pop once she was over the bed. She said she saw Resident #1 hit her head on the headboard. She said she pushed the call light for help. She said she yelled for help. She said she left the resident, but not for long. She said she knew she was not supposed to leave the resident, but she went and got the nurse in charge. She said she was an agency nurse. She said she stayed with Resident #1 after she got the nurse. She said she placed a cold towel on Resident #1 head. She said she did not remember if the nurse took her vitals. She said the other CNA on shift that night was putting her residents down. She said they try to put their residents at risk for falls down first. She said she would never transfer another resident with the Hoyer alone again. She said this was her first time doing this alone. She said she had been trained when she first started at the facility, but it had been a while. She said she has been at the facility for over a year. She said she has never had to demonstrate her ability to use the Hoyer lift. She said she had signed an in-service. During an interview on [DATE] at 10:45 AM, the Agency Nurse said she had not been oriented to the facility or their processes as an agency nurse. She said she did not receive a tour of the facility and was not oriented to any policies or what to do in an emergency according to the facility policy. During an interview on [DATE] at 11:11 AM, the On Call Charge Nurse stated she did orient the Agency Nurse to the facility procedures two days prior. She said she asked the Agency Nurse and said she did not have any questions. She said all nurses should know what to do in an emergency. She said the Agency Nurse was responsible for getting Resident #1 vitals. During an interview on [DATE] at 11:30 AM, CNA E stated she had not been checked off on the use of the Hoyer lift. She said she has never had to demonstrate her knowledge and ability to use the Hoyer lift. She said she has not been trained on a contingency plan in what to do if the one Hoyer they have was to stop working. She said she could use a sheet or get another staff to grab an arm and leg. She said the potential negative outcome of not having a contingency plan would be residents could get hurt. During an interview on [DATE] at 11:35 AM, CNA E stated that if Hoyer was not working, she would get the older one. She said they have a crank Hoyer that they can use. She said she does take vitals, but it was a nurse's duty. During an interview on [DATE] at 11:40 AM, CNA G stated she had been checked off to use the Hoyer lift. She said she has never had to demonstrate. She said if the Hoyer lift does not work, the facility has a manual Hoyer lift that they are supposed to use. She said she was agency staff and had never been oriented to the facility policy and procedures. She said she just used her prior knowledge. During an interview on [DATE] at 11:45 AM, CNA H stated she had training with a group while back at the facility but did not demonstrate it for competency. She said she was unaware of a contingency plan if the one Hoyer lift did not work. During an interview on [DATE] at 11:50 AM the DON stated improper use of the Hoyer lift can lead to serious injury even death. She said it could have been worse if CNA A had not been over the bed. She said not taking a resident's vitals after a fall would mean the staff do not know the status of the resident and they could be worse than what was physically seen. She said not having a contingency plan for the Hoyer could lead to the staff not having a way to transfer the resident. She said there was only one Hoyer because the older one had been decommissioned. She said the staff were no longer using the old Hoyer. She said she did not know where the Hoyer was. She said she was unaware that the staff had not demonstrated using the Hoyer. She said she knew that they went over how to use the Hoyer, but this was before she was hired. She said she was unaware that non-certified aides were using the Hoyer lift. She said she was unaware that there was staff using the Hoyer alone because of staffing. She said she was unaware that the Agency Nurse did not take the resident's vitals. She said she was also unaware that there was no formal contingency plan. Regarding systems in place to monitor the deficient practices, she said annual training should cover Hoyer's use. She said in her experience, she had to demonstrate her skills. She said regarding taking vitals, they have their accident policy. She said she did not have any additional support regarding a contingency plan to ensure things such as contingency plans were not missed. She said there was no system in place to monitor the staff using the Hoyer lift or taking vitals. She said she had to trust that they were doing their job. She said there was no documentation to support staff skill competency for the Hoyer lift. She said she had been trained on the use of the Hoyer when she worked at the hospital, but not at the facility. She said she had training regarding taking vitals after a resident had fallen. She said she had not received any training regarding a contingency plan. She said she expected staff to use the Hoyer with 2 staff. She said non-certified nurse aides should not use the Hoyer to transfer residents. She said they should not be a part of the 2 staff. She said non-certified nurse aides can observe. She said she expected the staff to be 100 percent trained and demonstrate their skills and use of the Hoyer. She said she expected agency staff to have all the skills and training before working in their facility. She expected additional staff to be used until they could secure a working lift. The DON did not specify what the staff would use to transfer. She said regarding Resident #1 and CNA A incident, she expected the CNA to use the Hoyer properly with two staff. She said she, as the DON, was responsible for monitoring the use of the Hoyer lift. She said the policy said the ADON was responsible, but since she was over the ADON, it was her responsibility. She said orienting agency staff was the responsibility of the same disciplines. She said if it was a CNA, a facility CNA staff would orient the staff. She said if it was a nurse, then a facility nurse would orient the agency nurse. She said she and ADM were responsible for ensuring a contingency plan was in place for transferring residents if the one Hoyer they had was unavailable. She said vitals should have been done as a part of the assessments after a resident falls. She said she has seen staff use the Hoyer in the past but never watched CNA A. She said a subdural hematoma was a serious diagnosis. She said it was a bleed under the subdural tissue. She said it was serious, so she was kept overnight. She said it was very important to take vitals because they could miss something, and with this diagnosis, a resident could rapidly deteriorate. During an interview on [DATE] at 12:00 AM, the ADM stated not training and ensuring that the staff know how to use the Hoyer lift would mean that they, as management, do not know if the staff truly know how to use it. She said staff not properly being trained can lead to injury or death. She said regarding the resident #1 incident, she could have died . She said it could have been much worse if Resident #1 had not been over her bed. She said non-certified nurse aides are not trained, and they could also hurt someone. She said that by not orienting the agency staff to facility policies and procedures or emergency response, the agency staff may not know what they are doing. She said agency staff may do things in a way that was not acceptable to the facility. She said not having a contingency plan could result in the staff breaking something on the residents. She said she was unaware that there were no physical competencies and that the staff did not demonstrate the use of the Hoyer back. She said she was unaware that her non-certified nurse aides were using the lift. She said she was unaware that the Agency Nurse did not take resident vitals. Regarding agency staff, she said she had never had to orient the agency staff. She said they should know what they were doing regarding their skills. She said she was unaware there was no contingency plan for if the Hoyer lift was to no longer work. She said she was unaware that CNA A was using the Hoyer alone. She said she had no system to monitor staff training for Hoyer use and demonstration. She said she did not have a system to monitor if the uncertified nurse's aides were using the Hoyer lift because they were not supposed to use the Hoyer because they had not been fully trained. She said there was no system in place to orient the agency staff. She said there was a book with emergency numbers. She said there was no system to monitor contingency plans for the Hoyer lift. She said she was not sure where the old Hoyer lift was. She said the staff should not be using it. She said there was a sit-to-stand one, but no one knew. She said she was unaware that CNA A had used the Hoyer by herself but believed if she had done it once she had done it more than once. She said she was unaware that other staff were using the Hoyer lift alone without a second staff. She said she had been trained in using the Hoyer and understood that staff should have demonstrated their use of the Hoyer. She said she has not personally been trained in taking vitals but understands that it has to be done after a fall. She said having a contingency plan had never been brought up. She said she expected all clinical staff to have been trained on using the Hoyer and should have physical competencies. She said she expected all staff to demonstrate to the Director of Rehab or the DON that they could properly use the Hoyer lift. She said it was not her expectation for staff to be just shown how to use the Hoyer. She said it was her expectation that the nurse in the facility take vitals after a fall. She said although she had seen CNAs take vitals, she had not seen them take them at her current facility. She said she understood that the CNA was trained to take vitals, but she did not want them taking vitals at the facility. She said the agency staff should know what comes with their respective discipline. For example, if they are a nurse, they should know all the skills and duties of a nurse. She said she expected if the agency staff had questions, they should ask them. She said with having one Hoyer lift, there should be a contingency plan in place to avoid injury and accidents. Regarding Resident #1 and CNA A, she expected the CNA to have retrieved another staff to help her and keep the resident safe from injury and accident. She said the DOR and the DON were responsible for completing physical competencies and ensuring that clinical staff demonstrated the use of the Hoyer per their policy and procedures. She said it was the responsibility of the DON and charge nurse to ensure that the uncertified nurse aides were not using the Hoyer lift and that other staff were not using the Hoyer lift alone. She said it was the responsibility of the charge nurse to ensure that vitals are taken after a resident falls or experiences any type of head trauma. She said not taking vitals after a potential head injury was unacceptable, especially with two nurses in the facility. She said the resident should not have been moved until assessed. She said overall, the DON was responsible for the activity of CNA A. The ADM confirmed that there were no physical competencies in the facility because they did not exist. She said Resident #1 Dx of subdural hematoma was serious because it was bleeding in the brain and Resident #1 could have bled out. She said taking vitals could have helped identify a serious issue with the resident neurologically. She said the staff may have had a chance to respond differently if vitals had been taken. During an observation that occurred on [DATE] at 1:37 PM CNA F and CNA I transferred Resident #3 from her wheelchair to the bed using the Hoyer lift. Prior to operation of the Hoyer neither staff inspected the sling to ensure it was intact and safe for use. CNA F & I did not lock the wheels of the Hoyer throughout the use of the Hoyer lift. During an observation that occurred on [DATE] at 1:52 PM CNA E and CNA J transferred Resident #1 from her wheelchair to her bed. Prior to operation of the Hoyer neither staff inspected the sling to ensure it was intact and safe for use. Resident #1 was one sided in the sling and no adjustments was made to ensure that the sling was evenly under the resident. Neither staff locked the Hoyer lift prior to using it to lift the resident out of her wheelchair. During an interview on [DATE] at 2:03 PM, Resident #3 stated that there was usually only one staff when staff transferred her. She was able to tell the surveyor her name but could not provide any information suggesting that she was oriented to time and place. During an interview on [DATE] at 2:04 PM, Resident #1 could not answer any questions regarding the incident on [DATE] and about past transfers with the Hoyer lift. During an interview on [DATE] at 2:10 PM, Resident #2 stated that staff used the Hoyer lift to transfer him, and most of the time, it was one staff. He was able to tell the surveyor his name and that he did not have any concerns. He said the staff were overall nice to him and that he was cold. During an interview on [DATE] at 2:18 PM, CNA K stated she had received training on [DATE]. She said they were shown by the DOR how to use the Hoyer. She said before [DATE], she had never had to demonstrate competency of the Hoyer lift. She said she did learn something new in the training. She said she never knew anything about the emergency release. She said if the battery had died or the resident was stuck in the air, she would have known how to release the Hoyer lift. She said that could have been very scary for the resident, but before her training on [DATE], she would have had to get help from a nurse or someone. During an interview on [DATE] at 2:31 PM, CNA E stated she had been trained on using the Hoyer lift on [DATE]. She said she had to demonstrate competence in using the machine but never had to prior to [DATE]. She said she was familiar with the machine but had not had training like the one she received at the facility on [DATE] in over 8 years. During an interview on [DATE] at 2:47 PM, LVN K stated she had only been back at the facility for a week. She said before her return, she never had to demonstrate her skills as a nurse or the use of the Hoyer lift. During an interview on [DATE] at 3:00 PM, RN M stated that she had been trained on the use of the Hoyer and was required to demonstrate the use of the Hoyer back to the DOR on [DATE]. During an interview on [DATE] at 3:10 PM, CNA N stated that she had never had to demonstrate her knowledge and use of the Hoyer lift before at the facility. She said she had worked at the facility five times as an agency staff member and had been briefed on some things but nothing in detail. She said she would work at night; most of the administration staff was gone. During an interview on [DATE] at 3:16 PM, NA O stated that before the Hoyer lift training she received on ,d+[DATE].23, she had never had to demonstrate her knowledge and use of the machine. She said she learned today that there was a red button that would let the resident down if the machine stopped working. She said without the training, she would not know what to do. She said she would have called for help. During an interview on [DATE] at 3:36 PM, MA P stated that she was a medication aide. She said she was also a CNA and sometimes helped staff with resident transfers. She said she had been trained on the Hoyer lift [AGE] years ago when she first obtained her CNA certification. Record review of the facility policy, Accidents and Incidents-Investigating and Reporting, Revised [DATE], revealed the following: Policy Statement All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. Policy Interpretation & Implementation a. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. b. The following data. as applicable, shall be included on the Report of Incident/Accident form: The condition of the injured person, including his/her vital signs; Record review of the facility policy, Fall Risk Assessment, Revised [DATE], revealed the following: Policy Statement The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident centered falls prevention plan based on relevant assessment information. Policy Interpretation and Implementation The attending physician and nursing staff will evaluate the resident's vital signs, assess the resident for medical conditions (such as those that cause dizziness or vertigo) or sensory impairments (such as decreased vision and peripheral neuropathy) that may predispose to falls. Record review of the facility policy, Safety Precaution, Lifting, Revised [DATE], revealed the following: Policy Statement All personnel shall follow safety precautions established by this facility when lifting or handling heavy objects. If the weight is too heavy or bulky for one (I) person to lift, seek assistance. Do not try to lift it alone. When lifting or moving residents, make sure that equipment is secure (i.e., wheelchair, beds, stretcher, etc.). If there are mechanical devices available to assist you in moving residents more safely, use them. Record review of the facility policy, Safe Lifting and Movement of Residents, Revised [DATE], revealed the following: Policy Statement In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. Back-up battery packs on remote chargers shall be provided as needed so that lifts can be used 24 hours a day while batteries are being recharged. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: o Involves employees in identifying problem areas and implementing workplace safety and injury- prevention strategies; o Provides training on safety. ergonomics and proper use of equipment; and o Continually evaluates the effectiveness of workplace safety and injury-prevention strategics. Record review of the Resident Hoyer lift inservice dated [DATE] revealed the following: 12 staff signed to include CNA A. Record review of the material accompanying the inservice dated [DATE] titled Patient Lifts Safety Guide, undated, revealed the following: Cover Page: This guide provides general safety recommendations and is not a replacement for the manufacturers instructions. Refer to manufacturer's instructions for specific use guidelines. Page 6: Prepare Environment, Determine number of caregivers needed: Most lifts require to or more caregivers to safely operate lift and handle patient. Page 7: Prepare Equipment: Ensure slings, hooks, chains, straps and supports are available, appropriate and correctly sized. Examine sling and attachment areas for tears, holes and frayed seams. Page 9: Perform Safety Check: Before lifting the patient, perform safety check: Examine all hooks and fasteners to ensure they will not unhook during use. Double check position and stability of straps and other equipment before lifting patient. Ensure clips, latches and bars are securely fastened and structurally sound. Record review of facility provided list, undated, revealed the following residents use the Hoyerlift: Resident #3 Hall 1 Resident #1 Hall 4 Resident #2 Hall 1 Record Review of the Employee Information Roster dated [DATE] revealed a total of 28 clinical staff that provide care for all residents in the facility. Record review of the facility provided list of agency staff workers included 7 agency clinical staff that provide care to all residents at the facility. Record Review of the Hoyer lift User Instruction Manual, undated, but obtained on [DATE] ( https://www.joerns.com/wp-content/uploads/,d+[DATE]/Hoyer-HPL700-User-Manual.pdf ) revealed: Page 4: WARNING: Important safety information for hazards that might cause serious injury. CAUTION: Information for preventing damage to the product. NOTE: Information to which you should pay special attention. DO NOT lift a patient unless you are trained and competent to do so ALWAYS lock the wheels when lifting from the floor. Page 15: CAUTION Have someone assist you when attempting to transfer a patient. Page 16: WARNING: recommends that slings be checked regularly and particularly before use for signs of fraying or damage. DO NOT use slings that are worn or damaged. Record review of the competency check list (undated) included the following criteria: Mechanical lift pre operations check: understands why resident needs this lift. demonstrates how to charge lift and locate batteries. demonstrates the ability t [TRUNCATED]

Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 7 out of 30 (06/17/23, 06/18/23, 06/23/23, 07/01/23, 07/02/23, 07/03/23, and 07/07/23) days reviewed for RN coverage. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for the following days: 06/17/23, 06/18/23, 06/23/23, 07/01/23, 07/02/23, 07/03/23, and 07/07/23 This failure could place residents at risk for inconsistency in care and services. Findings include: Record review of the facility's employee roster undated revealed there were four RNs employed at the facility. Record Review of time sheet provided by the Administrator dated 07/10/23 for the time period 06/10/23-07/10/23 revealed the following dates did not have RN coverage for at least 8 hours a day: 06/17/23, 06/18/23, 06/23/23, 07/01/23, 07/02/23, 07/03/23, and 07/07/23. Record Review of time sheet provided by the DON dated 07/12/23 for the time period 06/01/23-07/31/23 revealed the following dates did not have RN coverage for at least 8 hours a day: 06/17/23, 06/18/23, 06/23/23, 07/01/23, 07/02/23, 07/03/23, and 07/07/23. During an interview on 07/12/23 at 09:30 AM with the ADON, she stated the RN worked night shift from 06:00 PM to 06:00 AM. She stated she worked 6 hours from 12:00 AM to 06:00 AM and came back and worked 6 hours 06:00 PM to 12:00 AM. She stated no other RN worked before or after her shift. She stated that was over 12 hours for the day but was not consecutive. She stated she had never been told it had to be consecutive. She stated missing time punch for Infection Control Preventionist was because she worked from home. During an interview on 07/12/23 at 11:25 AM with the DON, she stated the RN staff were responsible for RN coverage. She stated she was not sure what the facility policy was, she would have to look at policy. She stated it was important to have an RN available to staff. She stated the facility had an ad in paper advertising for an RN. She stated they used agency nurses but not RN's. She stated her expectations was to be in compliance. She stated the difference between an RN and LVN was higher education and skills. She stated she worked Monday through Friday 8 hours a day and every other weekend. She stated she was on-call all the time. During an interview on 07/12/23 at 01:20 PM with the ADM, she stated the DON was responsible for RN coverage. She stated the DON and Infection Control Preventionist was on call and would make sure one was available at all times. She stated she had not seen a policy, but she knew they were required to have 8 consecutive hours a day. She stated she does not see how it could negatively affect the residents. She stated, if it was a RN task, the LVN will call the RN and the MD only lives 20 minutes away. She stated they had an ad in the local newspaper. She stated they have used agency but do not use RN's because they usually need LVNs. She stated the staff RNs shared the weekends. She stated her expectations was to have RN coverage for 8 consecutive hours a day. She stated they do not have a system in place to monitor RN coverage. She stated the difference between a RN and a LVN was the RN can do more. She stated, most RN's make better decision than LVN because they have had more education. She stated the DON worked 8 hours a day Monday through Friday and alternates weekends. Record review of the help wanted ad in the Texas Spur Newspaper dated 07/13/23 revealed [NAME] County Nursing Home is hiring a Full-Time Night Nurse During an interview on 07/12/23 at 02:00 pm with the DON surveyor requested facility policy on RN Coverage no policy was provided. During exit conference 07/12/23 at 03:45 PM ADM was asked if there were any additional information, they want to present that was requested, she stated No.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: 1)The facility failed to ensure foods were processed under sanitary conditions, 2) The facility failed to ensure Dietary staff dated and labeled foods as required, 3) The facility failed to ensure Dietary staff maintained chlorine sanitizer levels within acceptable ranges in wiping cloth solutions. 4) The facility failed to ensure Dietary staff ensured food contact surfaces were clean, 5) The facility failed to ensure food contact equipment was stored in a manner to air dry, 6) The facility failed to ensure the fly population was effectively controlled in the kitchen, and 7) The facility failed to ensure Dietary staff ensured that foods were not held past the manufacturers recommended expiration date, and 8) The facility failed to ensure staff used effective hair restrains. These failures could place residents at risk for food contamination and foodborne illness. The findings include: The following observations were made, and interviews conducted during a kitchen tour on [DATE] that began at 10:20 AM and concluded at 10:42 AM: In the walk-in refrigerator, there was a bag of sliced ham in a re-sealable zipper storage bag that was labeled, Pulled [DATE]. The original container of sliced ham had been opened. It was further labeled on a Ziploc bag Use by [DATE]. There was a Ziploc bag of sliced American cheese in the walk-in refrigerator that had been opened and label/date was not readable and was blurred. There was a bag of cheese in the walk-in refrigerator that stated on the original bag [DATE]. On the exterior Ziploc bag is stated Pulled [DATE]. There was a fly crawling on the can opener and there were 4 flies crawling on the service line. There were stacks of plastic measuring containers stacked inverted but were wet. The following observations were made, and interviews conducted during a kitchen tour on [DATE] that began at 11:18 AM and concluded at 12:50 PM: Puree preparation was observed. Observation revealed the interior of the blender was wet on the interior. Dietary staff A placed cookies and milk in the blender and pureed it. The blender was not allowed to air dry prior to use. She next pureed the bean corn salad. Observation revealed that the blender was wet on the inside. She placed the bean/corn salad and thickener in the blender and pureed it. The blender was then washed. After washing, the surveyor intervened and checked the blender, and it was wet on the interior and had some food debris. Dietary staff A took it away and re-washed it. The second processor used was wet on the interior. She then placed slices of bread and milk in the blender and pureed it. There were flies on the floor. Two were crawling on the prep table area pole. Further observation revealed there was no fly trap or other fly deterrent in the kitchen. During an interview with Dietary staff B on [DATE] at 11:31 AM, she stated regarding the flies, They are everywhere. The plastic containers were still inverted and stacked wet on the lower shelf of the prep table. There was a fly crawling on the processor station. There was also a fly crawling on the pan of chili/beans and there were two crawling on the menu book. Four flies were landing on the box of plastic wrap, microwave, menu book. The storage sheath for the yellow digital thermometer had food debris on the interior. The Maintenance Supervisor entered the kitchen and scooped ice in a cup from the ice machine and dispense some tea. He had long hair and his hair was not effectively restrained with his cap. The trashcan was uncovered during the meal service. On [DATE] at 11:40 AM, the Dietary Manager was interviewed regarding the fly situation. She stated, the fly problem showed an increase in June due to the rain. She added that there was little they could do and that they kept the kitchen doors shut. She added that there was an ultraviolet light fly trap in the auxiliary hall near the laundry and adjacent to the kitchen. She stated she felt the fly trap had not been very effective. On [DATE] at 11:50 AM an interview and observation were conducted with the Maintenance Supervisor regarding the flies. He stated the ultraviolet fly trap was the only one in the facility. He added the pest control operator came every two weeks and treated certain areas for flies. Observation revealed an ultraviolet fly trap in the auxiliary hall alcove, approximately 8 feet from the entrance/back entrance door. - The following observations were made, and interviews conducted during a kitchen tour on [DATE] that began at 9:28 AM and concluded at 9:39 AM: Dietary staff A was observed taking a wiping cloth from a wiping cloth solution in the sink and wiping down food preparation tables. The wiping cloth solution was tested , and it had greater than 200 ppm chlorine sanitizer in it, which was a toxic level of chlorine. Regarding who made the solution, Dietary staff A stated, she did not know because someone else made up the solution before she arrived. In the walk-in refrigerator, there was a re-sealable zipper storage bag of sliced American cheese that had no date and had been opened. The sheath for the yellow digital thermometer was dirty on the interior with food debris. - The following observations were made during a kitchen tour on [DATE] that began at 12:49 PM and concluded at 1:15 PM: Observation of the stacked plastic containers on the lower shelf of the food preparation table revealed that they were stacked wet. On [DATE] at 9:40 AM, an interview and observations were conducted with the Dietary Manager regarding observations in the dietary department. Observation of the walk in refrigerator at this time revealed that there was a bin of Vital Vanilla Mighty Shakes Reduced Sugar Nutritional Shakes 4 ounce. There was a sign on the bin documenting [DATE]. The Dietary Manager stated at the time this was the date when the shakes were taken from the freezer and placed in the refrigerator. She stated it took 2 to 3 days for them to thaw. Observation and record review of one of the cartons of shake revealed the following, Store frozen. Thaw at or below 40 F. Use thawed product within 14 days. Keep refrigerated. Regarding whom monitors the dates on foods to ensure that they are not expired, the Dietary Manager stated it was on her. Regarding the processor/blender being wet and foods processed in it, she stated staff should have waited until the processor was dry. Observation at this time revealed that there were containers stacked inverted, but still wet and were stored on the lower shelf of the prep table. Regarding the trashcan being uncovered during meal service, she stated staff left it open so as not to touch the lid. Regarding the wiping cloth solution being greater than 200 ppm chlorine, she stated it should have been 50 ppm chlorine. Regarding if she had conducted any in-services on dating and labeling foods or other dietary issues, she stated she had spoken to staff individually and had conducted a hand washing in-service about a month ago. Regarding new employee training, she stated that the training was 2 to 3 weeks in length. Regarding why she thought these discussed issues happened in the dietary department, she stated staff would get in a hurry and were ready to go home. She also stated she tried to follow behind staff and label items they missed. Regarding whom was responsible for ensuring that dietary duties were conducted correctly, she stated the responsibility fell on her. She added she tried to do too much herself. Regarding what could result from the issues found in the dietary department, she stated it could make residents ill. Regarding what she expected staff to do regarding the dietary sanitation issues, she stated she expected the staff to do the correct things and to correct the situation. Record review of the Code of Federal Regulation, Title, 21, Volume 3, CITE: 21, CFR 178.1010, TITLE 21 - FOOD AND DRUGS, CHAPTER 1 - FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES, SUBCHAPTER, B - FOOD FOR HUMAN CONSUMPTION (CONTINUE), PART 178 - INDIRECT FOOD ADDITIVES: ADJUVANTS, PRODUCTION AIDS, AND SANITIZERS, Subpart B - Substances Utilize To Control The Growth Of Microorganisms, SCC. 178.1010 Sanitizing Solutions, current as of [DATE], revealed the following documentation, .Sanitizing solutions may be safely used on food-processing equipment and utensils, and on other food-contact articles as specified in this section, within the following prescribed conditions: (a) Such sanitizing solutions are used, followed by adequate draining, before contact with food. (b) The solutions consist of one of the following, to which may be added components generally recognized as safe and components which are permitted by prior sanction or approval. (1) An aqueous solution containing potassium, sodium, or calcium hypochlorite, with or without the bromides of potassium, sodium, or calcium . c)The solutions identified in paragraph (b) of this section will not exceed the following concentrations: (1) Solutions identified in paragraph (b)(1) of this section will provide not more than 200 parts per million of available halogen determined as available chlorine. On [DATE] at 2:16 PM, the administrator was interviewed regarding dietary sanitation issues in the facility. She stated that the Dietary Manager was responsible and that she expected dietary staff to correct what they had done wrong. Regarding what could result from these issues, she stated residents could become ill. Record review of the dietary in-services for the last four months (March - [DATE]) revealed That there was one in-service titled handwashing dated [DATE]. Dietary staff B attended the in-service. No other in-services were presented for that time period. Record review of the current undated facility policy, titled Dietary Department, revealed the following documentation, Purpose. The dietary department will work to comply with all state, federal and local infection control, standards and regulations concerning personnel, requirements, food storage, preparation, handling and serving; sanitizing equipment, and utensils; and isolation procedures, and techniques. Dietary employees are required to: . 4. Wear a hair restraint, such as caps, hair, coverings, or nets, beard restraints, and clothing, that cover body hair to keep hair from contacting exposed food, clean equipment, utensils, and linens in food prep areas. Policies for Food Preparation and Serving: 1. All equipment must be cleaned and sanitized before use. Equipment Care and Storage: . 2. Keep trash cans, and garbage cans covered while they remain in the building or kitchen area. 8. Clean and sanitize all food, grinders, choppers, and mixers after each use. Housekeeping Duties. 2. Clean and sanitize food surfaces, utensils, and equipment after each use. Also clean counters every day and when needed. 8. The kitchen should undergo pest and rodent control procedures once a month.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in the kitchen, dining room, 2 of 2 sunrooms, auxiliary hall, 4 of 14 rooms (room [ROOM NUMBER], 200, 202 and 401) and rotunda, in that: 1)Live Flies were observed flying and crawling in kitchen, dining room, 2 of 2 sunrooms, auxiliary hall, 4 of 14 rooms (room [ROOM NUMBER], 200, 202 and 401), and 2) The pest control program was further compromised due to having limited fly deterrents placed in and around the facility. These failures could place residents at risk for foodborne illness and infections. The findings include: ~ The following observations were made during a kitchen tour that began on 7/10/23 at 10:20 AM and concluded at 10:42 AM: They were 4 flies crawling on the service line and a fly crawling on the can opener. A confidential Interview was conducted with a resident in the dining room. The resident stated, The flies are about to eat me up right here. ~ The following observations were made during a kitchen tour that began on 7/10/23 at 11:18 AM and concluded at 12:36 PM: There were flies on the floor and two were crawling on the prep table area pole and processor station. There was a fly crawling on the pan of chili/beans and two crawling on the menu book. Four flies were landing on the box of plastic wrap, microwave, and menu book. There were no fly UV traps or other fly deterrents in the kitchen. During an interview with Dietary staff B on 7/10/23 at 11:31 AM, she stated the flies were everywhere. On 7/10/23 at 11:40 AM, the Dietary Manager was interviewed regarding the fly situation. She stated, the fly problem showed an increase in June due to the rain. She added that there was little they could do and that they kept the kitchen doors shut. She added that there was an ultraviolet light fly trap in the auxiliary hall near the laundry and adjacent to the kitchen. She stated she felt the fly trap had not been very effective. On 7/10/23 at 11:50 AM, an interview and observation were conducted with the Maintenance Supervisor regarding the flies. He stated the ultraviolet fly trap was the only one in the facility. He added the pest control operator came every two weeks and treated certain areas for flies. Observation revealed an ultraviolet fly trap in the auxiliary hall alcove, approximately 8 feet from the entrance/back entrance door. Observation on 7/10/23 at 12:35 PM Resident #25 was observed in the dining room and there was a fly on her plate. Observation on 7/10/23 at 7/10/23 at 2:51 PM there were dead flies lining the auxiliary hall window area near the rear entrance. There were 11 dead and one live. This was the auxiliary hall adjacent to the kitchen. ~ The following observations were made during a kitchen tour that began on 7/10/23 at 5:40 PM and concluded at 5:57 PM: There was a live fly in the dishwasher area. Observation on 7/10/23 at 6:03 PM room [ROOM NUMBER], Resident #8 was in bed and there was a fly on the G-tube flushing syringe bag. Observation on 7/10/23 at 6:44 PM, a general tour was conducted of the facility. Observations revealed there were no ultraviolet fly traps or visible fly deterrents in the rotunda/nurse station area, dining room, 4 of 4 halls, both sunrooms that led to resident use patios or the rest of the building. Observation on 7/11/23 at 9:49 AM in room [ROOM NUMBER] had a live fly in the room Observation on 7/11/23 at 10:25 AM in room [ROOM NUMBER] Resident #1 was in bed asleep, and there was a live fly in the room. During the Resident Council meeting confidential interview on 7/11/23 at 2:05 PM, two of nine residents voiced issues regarding the fly population in the facility. One resident stated the flies were mostly in the kitchen and that they were bad in the dining room today (7/11/23). The resident added that residents would go outside which caused the flies to enter the facility. The resident further stated the facility needed to control the entrances regarding flies and some flies were seen in resident rooms. During an observation on 07/11/23 at 02:47 PM during incontinent care with Resident #19 (room [ROOM NUMBER]) provided by CNA B there were multiple flies crawling and flying around resident's head and around surveyor standing at foot of bed. Resident #19 and CNA B swatted at flies several times. During all 3 days of the survey, general observations were made of staff and residents going outside via the 2 sunroom exit doors to the outside. These observations included an observation of Resident #7 on 7/11/23 at 4:57 PM outside on the patio located between halls 100 and 200. ~ The following observations were made during a kitchen tour that began on 7/12/23 at 9:400 AM and concluded at 10:03 AM: There were flies in the kitchen and there was a fly on the covered large mixer. Observation on 7/12/23 at 10:04 AM revealed there was a fly in the dining room on the large wooden table. On 7/12/23 at 10:47 AM, an interview was conducted with the Maintenance Supervisor regarding pest/flies. He stated every two weeks the pest control operator came to spray the facility. Regarding the fly trap in the auxiliary hall, he stated that was the only one. He stated, periodically the facility baited the dumpsters for flies, but was not sure the last time they placed fly bait at the dumpsters. He added the facility's property was adjacent to property with cows and flies were always an issue in the summer. Regarding whom was responsible for ensuring that the fly population was minimized in the facility, he stated himself and the pest control operator. Regarding how he monitored the population of the flies, he stated he watched the back door area windows next to the kitchen. He added the pest control operator also placed bait in the auxiliary hallway windows and the housekeeper sweep the area daily for the flies. Regarding what could result from the fly issues in the facility, he stated, residents would not want to eat, and the situation would gross them out. He further stated that he had not really requested more of the ultraviolet fly traps. Observation on 7/12/23 at 11:01 AM there was a live fly in the dining room. Observation on 7/12/23 at 11:19 AM, Resident #6 was seated in the sunroom between halls 300 and 400 and was swatting flies in the sunroom with a swatter. There was a fly in the sunroom. On 7/12/23 at 2:16 PM, the Administrator was interviewed regarding the fly control issue. She stated that the Maintenance Supervisor was responsible, and she expected that the flies be killed. She added the result of the fly issue could be resident annoyance, lots of things and open wounds issues. Record review of the Pest Control Operator's Service Slip/Invoice for the work dates of 6/2/23 and 6/16/23 revealed that the target pests for both visits were roaches. The description of service was, Pest Service - twice monthly service. Record review of the email dated 7/12/23 from the Administrator to the Pest Control Operator revealed that the chemicals used were Demand CS and Crossfire Concentrate and Aerosol for the visit. Record review of the Syngenta website (https://www.syngentapmp.com/product/demand-cs-insecticide) revealed that the Demand CS product was used for flies. Record review of a facility policy, titled Operational Policy and Procedure Manual for Long-Term Care, Revised May 2008, Physical Environment - Pest Control, revealed the following documentation, Pest Control. Policy Statement. Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation. 1. This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. 6. Maintenance services assist, when appropriate and necessary, in providing pest control services.