Every finding on record at Kirkland Court Health and Rehabilitation Center

Based on observation, interview and record review, the facility failed to implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 5 (Resident #6, #9, #21, #28, and #35) of 19 residents reviewed for comprehensive care plans. -The facility failed to ensure Resident #6, #21 and #28's bedrails were not referred to as restraints in their care plans. - The facility failed to ensure Resident #9's scoop mattress and bed rails were not referred to as restraints in her care plan. - The facility failed to ensure Resident 35's bed and chair alarms and scoop mattress were not referred to as restraints in her care plan. This failure could result in residents not being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being.Findings included: Resident #6 Record review of Resident #6's face sheet dated 08/24/26 revealed a [AGE] year-old female resident admitted to the facility on [DATE] and 12/12/25 with diagnoses to include coronary artery disease (damage or disease in the hearts major blood vessels), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), and anxiety disorder (a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Record review of Resident #6's admission MDS printed 08/25/26 and completed 7/25/26 listed her with a BIMS of 12 indicating she was moderately cognitively impaired, and she had a functionality of requiring substantial/maximal assistance when lying sitting on the side of the bed. Resident #6 was listed with no impairment of upper extremity's (shoulders, elbow, wrist, hand). Section P Restraints and Alarms revealed Resident #6 was not coded as having bed rails as a restraint. Record review of Resident #6's order summary with Active Orders as of: 8/25/26 revealed the following order: 1/4 side rails to both sides for mobility and independence. Verbal Active 07/31/2025. Record review of Resident #6's care plan printed 8/25/26 with date of admission [DATE] revealed the following: Focus: The resident uses physical restraints 1/4 siderails. Date Initiated: 08/06/2025. Revision on: 08/06/2025.Goal: The resident will remain free of complications related to restraint use, including contractures, skin breakdown, altered mental status, isolation or withdrawal through review date. Date Initiated: 08/06/2025. Target Date: 11/05/2026Interventions: Anticipate and intervene for potential causes which have precipitated prior falls or accidents. Date Initiated: 08/06/2025. Ensure The resident is positioned correctly with proper body alignment whilerestrained. Date Initiated: 08/06/2025 Ensure valid consent on chart prior to initiating restraint. Date Initiated: 08/06/2025. Record review of Resident #6's clinical record revealed a Restraint-Physical (Initial Evaluation) completed 7/18/25 with DECISION TO RESTRAIN - no restraint indicated. During an observation on 08/24/2026 at 6:43 AM Resident #6 was in her bed sleeping peacefully with the HOB and feet elevated. Observed were bilateral 1/8 bedrails up and locked in place. Resident #6 did not wake to knocking or introduction. During an observation of Resident #6's wound care on 08/25/2026 at 2:02 PM Resident #6 was observed using her bilateral bedrails to roll from right to left and back to her left side. Resident #6 was interviewed and reported she used the bedrails for positioning, she was aware of how to use the bedrails for mobility and does not care about putting the bedrails up or down. Resident #9 Record review of Resident #9's admission record dated 08/25/26 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, muscle wasting and atrophy, fracture of femur (broken leg), and fracture of sacrum (broken pelvis). Record review of Resident #9's annual MDS assessment completed on 07/24/26 revealed a BIMS score of 13 indicating intact cognition. Section GG Functional Abilities revealed Resident #9 had impairment on both upper and lower extremities. She was noted to require supervision or touching assistance to roll from side to side, move from sitting to lying, and move from lying to sitting. Resident #9 required partial/moderate assistance with moving from sitting to standing and substantial/maximal assistance with transferring between her bed and wheelchair. Section P Restraints and Alarms revealed she was not coded as having bed rails as a restraint. Scoop mattress was not listed as an option for restraints. Record review of Resident #9's care plan completed on 07/28/26 revealed the following focus area initiated on 12/18/25 and revised on 07/16/26, The resident uses physical restraints half bedrails for bed mobility and positioning. The resident uses scoop mattress dt resident risk to roll OOB. One of the interventions listed for this focus area was, Ensure valid consent on chart prior to initiating restraint. She was noted to be a high risk for falls and required a scoop mattress. Record review of Resident #9's active orders dated 08/25/26 revealed the following orders with corresponding start dates:12/17/25 1/2 side rails for bed mobility and positioning12/17/25 Scoop mattress for safety and fall prevention Record review of Resident #9's Restraint - Physical (Initial Evaluation) dated 12/17/25 revealed she was receiving a restraint of scoop mattress due to falling, attempting to self-transfer, and climbing out of bed. One of the options listed as an attempted alternative prior to installing the restraint of a scoop mattress was bed rails.Record review of Resident #9's Informed Consent for Use of Restraints dated 12/17/26 revealed the recommended restraints were bed and chair alarms and a scoop mattress. The consent was given by phone to ADON by Resident #9's family member.Record review of Resident #9's Bed Rail Consent dated 12/17/26 revealed bed rails may be beneficial for use a [sic] mobility aid. It can enable resident to reposition self, [sic] or assist in repositioning self either side-to-side or upward/downward and can assist resident in safely entering or exiting bed. Resident #9's family member consented to the use of bed rails. Record review of Resident #9's most recent Bed Rail Safety Review dated 07/17/26 revealed Resident #9 was able to get in and out of bed safely, move from lying to sitting/standing independently, and reposition herself independently. Bed rails for Resident #9 were noted to promote mobility and transfers. During an observation on 08/24/26 at 06:26 AM Resident #9 was lying in bed with bilateral 1/2 bed rails in the upright position. Her mattress appeared to be a scoop mattress. During an observation and interview on 08/25/26 at 09:32 AM Resident #9 was seated in her wheelchair next to her bed. Her bed had bilateral, upright bed rails and scoop mattress in place. She stated she used the bed rails to move around in her bed and get into and out of bed. She stated she felt the bed rails helped her not fall out of bed. During an interview on 08/26/26 at 9:44 AM ADM stated Resident #9's bed rails and scoop mattress did not restrain her. She stated it was more safety and preference for Resident #9. During an interview on 08/26/26 at 09:59 AM MDS RN stated Resident #9's bed rails were to help her get in and out of bed more safely, turn and reposition, and be independent. She stated bed rails were technically considered restraints and that was why they were listed on Resident #9's care plan as restraints. She stated Resident #9 was able to transfer herself into and out of bed. During an interview on 08/26/26 at 10:23 AM CNA A stated Resident #9 was able to get out of bed and was able to move her body freely in bed and reposition herself as desired. Resident #21 Record review of Resident #21's face sheet dated 08/24/26 revealed a [AGE] year-old male resident admitted to the facility on [DATE] and 10/05/25 with diagnoses to include diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant), legal blindness (visual acuity less than 20/200), acquired absence of right leg below the knee, acquired absence of the left leg below the knee, and dependence on renal dialysis (a lifesaving medical treatment that removes extra fluid and harmful wastes from the blood when the kidneys fail). Record review of Resident #21's annual MDS printed 08/25/26 and completed 7/10/26 listed him with a BIMS of 15 indicating he was cognitively intact, and he had a functionality of requiring partial/moderate assistance when lying sitting on the side of the bed. Section P Restraints and Alarms revealed Resident #21 was not coded as having bed rails as a restraint. Record review of Resident #21's order summary with Active Orders as of: 8/25/26 revealed the following order: 1/2 side rail for repositioning/mobility/safety Verbal Active 07/11/2024. Record review of Resident #21's care plan printed 8/25/26 with date of admission [DATE] revealed the following: Focus: The resident uses physical restraints 1/2 siderails r/t bed mobility and positioning. Date Initiated: 01/08/2026. Revision on: 01/08/2026Goal: The resident will remain free of complications related to restraint use, including contractures, skin breakdown, altered mental status, isolation or withdrawal through review date. Date Initiated: 01/08/2026. Target Date: 10/21/2026Interventions: Anticipate and intervene for potential causes which have precipitated prior falls oraccidents. Date Initiated: 01/08/2026 Ensure The resident is positioned correctly with proper body alignment whilerestrained. Date Initiated: 01/08/2026 Ensure valid consent on chart prior to initiating restraint. Date Initiated: 01/08/2026. Record review of Resident #21's clinical record revealed a Restraint-Physical (Quarterly/Annual Evaluation) completed 1/10/26 with RECOMMENDATIONS - no restraint indicated. During an observation and interview on 08/24/2026 at 6:49 AM Resident #21 was in his room sitting in his wheelchair. Resident #21 appeared in good condition and was observed to have bilateral below the knee amputations with prosthetic legs. Resident #21 was able to move his upper body freely. Resident #21 had bilateral 1/3 bedrails up and locked in place on his bed. Resident #21 reported he used the bedrails frequently to get in and out of bed and move around in the bed. Resident #28 Record review of Resident #28's face sheet dated 08/24/26 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), malignant neoplasm of the colon and rectum (an abnormal mass of tissue caused by uncontrolled cell division that is cancerous and can invade nearby tissues, or spread to other parts of the body), and osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down). Record review of Resident #28's admission MDS printed 08/25/26 and completed 6/05/26 listed her with a BIMS of 14 indicating she was cognitively intact, and she had a functionality of being independent when lying sitting on the side of the bed. Section P Restraints and Alarms revealed Resident #28 was not coded as having bed rails as a restraint. Record review of Resident #28's order summary with Active Orders as of: 8/25/26 revealed the following order: 1/2 side rails for bed mobility and positioning. Verbal Active 07/11/2025. Record review of Resident #28's care plan printed 8/25/26 with date of admission [DATE] revealed the following: Focus: The resident uses half side rails for bed mobility and positioning. Date Initiated: 07/21/2025. Revision on: 07/21/2025Goal: The resident will remain free of complications related to restraint use, including contractures, skin breakdown, altered mental status, isolation or withdrawal through review date. Date Initiated: 07/21/2025. Target Date: 09/16/2026.Intervention: Anticipate and intervene for potential causes which have precipitated prior falls oraccidents. Date Initiated: 07/21/2025 Ensure The resident is positioned correctly with proper body alignment whilerestrained. Date Initiated: 07/21/2025 Ensure valid consent on chart prior to initiating restraint. Date Initiated: 07/21/2025. Record review of Resident #28's clinical record revealed a Restraint-Physical (Quarterly/Annual Evaluation) completed 6/04/26 with RECOMMENDATIONS - continue. Comments/Reason for decision: Assist in safety with transfers/mobility per resident request. During an observation and interview on 08/24/2026 at 6:15 AM Resident #28 was in her room sitting at the side of her bed. Observation revealed bilateral 1/8 bedrails up and locked in place. Resident #28 reported she used the bedrails to move around in bed and she knew how to use the bedrails to include getting them up and down. Resident #35 Record review of Resident #35's admission record dated 08/25/26 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), dementia (a group of thinking and social symptoms that interfere with daily functioning), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), and osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes or deficiency of calcium of vitamin D). Record review of Resident #35's quarterly MDS assessment completed on 08/05/26 revealed a BIMS score of 8 which indicated moderately impaired cognition. Section GG Functional Abilities revealed Resident #35 required supervision or touching assistance with rolling side-to-side and moving from sitting to lying. She required substantial/maximal assistance with transferring between her wheelchair and her bed. Section P Restraints and Alarms revealed Resident #35 had no restraints and had a bed and a chair alarm. There was no area to code a scoop mattress, bed alarm, or chair alarm as a restraint. Record review of Resident #35's care plan completed on 08/05/26 revealed the following focus area initiated on 07/14/26 and revised on 07/29/26, The resident uses physical restraints Bed/chair alarms, scoop mattress r/t fall risk. One of the interventions listed for this focus area was, Ensure valid consent on chart prior to initiating restraint. Record review of Resident #35's active orders dated 08/25/26 revealed the following orders with corresponding start dates:06/26/26 May have a scoop mattress two times a day06/29/26 May have bed/chair alarm every shift Record review of Resident #35's Restraint - Physical (Initial Evaluation) dated 06/29/26 revealed she was receiving a restraint of bed/chair alarm due to multiple attempts to get up by herself and multiple falls. Resident #35's family member gave consent for physical restraints by phone. Record review of Resident #35's Informed Consent for Use of Restraints dated 06/29/26 revealed her family member gave consent for bed and chair alarms and a scoop mattress. During an observation on 08/24/26 at 06:29 AM Resident #35 was lying on her back in bed. Her mattress appeared to be a scoop mattress. The bed alarm on her bed began to go off and within two minutes two CNAs entered her room and turned the alarm off. During an interview on 08/24/26 at 02:40 PM Resident #35's family member stated the bed alarm was placed on her bed to help staff know when she was trying to get up on her own. He stated he and staff had attempted to educated Resident #35 that she had to call for assistance when she wanted to get out of bed or out of her wheelchair but she forgets to call for help and had many falls at her previous facility so the decision to place alarms on her bed and chair was made for her safety. He stated he did not think the alarm limited Resident #35's movement. He stated he visited Resident #35 every day and he felt the alarm was simply to notify staff of Resident #35's attempts to self-transfer. Resident #35's family member stated Resident #35 still attempted to get herself out of bed and was able to move her body freely while in bed. During an interview on 08/26/26 at 9:44 AM the ADM stated Resident #35's bed alarm, chair alarm, and scoop mattress did not restrain her. She stated it was more safety and preference for Resident #35. During an interview on 08/26/26 at 09:59 AM the MDS RN stated Resident #35's bed alarm, chair alarm, and scoop mattress did not restrain her movement and were there to help her not fall and to notify staff if she was attempting to self-transfer. She stated she did not think the alarms or mattress would limit Resident 35's access to her body or movement of her body. During an interview on 08/26/26 at 10:23 AM CNA A stated Resident #35 was able to move her body freely in bed and reposition herself as desired. She stated Resident #35 occasionally attempted to transfer herself and the bed and chair alarms alerted staff so staff could assist her with transfers. During an interview on 08/26/2026 at 9:44 AM the ADM reported the facility policy considers bedrails as a restraint, but she does not consider the bedrail a restraint because all 4 residents using bedrails can move around in bed easily, can transfer if needed, and the bedrail does not restrict their access to their body. The ADM reported the bed and chair alarms were the same way. They did not restrict the resident's ability to move freely and neither resident was afraid of the alarm. The alarms were only used for resident safety. The ADM reported if the care plan does not accurately reflect the resident's condition and care then everybody would not be aware of what the resident needs. During an interview on 08/26/2026 at 9:59 AM the MDS RN reported she was responsible for completing care plans. The MDS RN reported the facility currently care plans bedrails as a restraint, technically they were not a restraint because each of the 4 residents listed for using bedrails have freedom of movement and do not meet the definition of a restraint. The MDS RN reported the definition of a restraint was any manual method or physical or mechanical device attached or adjacent to their body that they cannot remove easily restricts freedom of movement or normal access to their body. The MDS RN reported the bedrails were not being used to keep the residents on their beds. The bedrails were being used to promote the resident's ability to move in bed. The MDS RN verified the bedrails were not addressed on the MDS as a restraint because they are not considered a restraint by definition of the RAI manual. It's different and we are not using them as a restraint. The MDS RN read the residents care plans and reported each resident was listed as using a physical restraint in the bedrail care plan section and she needed to add the information from the physician order that the bedrails were for mobility and independence. During an interview on 08/26/2026 at 10:16 AM the DON reported the facility did advice the staff to consider bedrails as a type of restraint, but she did not feel that any of the 4 residents that were using bedrails were using them as a restraint because they can move freely in bed. The DON reported the bedrail was not a restraint and the residents use the bedrail mainly for bed mobility. The DON reported if the care plan for a resident was not accurate then it would be hard for staff to follow the needs of the residents. Record review of the facility provided policy titled Care Plans: Comprehensive Person-Centered revised 3/2022, revealed the following: 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensives assessment.7. The comprehensive, person-centered care plan:b. describes the services that re to be furnished to attain or maintain the resident highest practicable physical, mental, and psychosocial well-being.e. reflects currently recognized standards of practice for problem areas and conditions. Record review of the facility provided policy titled, Proper Use of Side Rails revised 12/2016 revealed the following: Purpose: The purpose of these guidelines are to ensure the safe use of side [NAME] as resident mobility aides and to prohibit the use of side rails as restraints unless necessary to treat a resident medication symptoms.[NAME] Guidelines: Siderails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed).

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food was properly stored, labeled, and dated.The facility staff failed to practice proper hand hygiene.The facility staff failed to wear hairnets in the kitchen. These failures could place residents who ate food served by the kitchen at risk of food-borne illness and weight loss.Findings included:In an observation on 08/24/2026 at 6:03 AM, 4 bags of an unknown yellow liquid substance were found in a silver serving pan, not labeled, not dated in the walk-in refrigerator located in the kitchen. In an observation on 08/24/2026 at 6:07 AM, on a shelf above a small table holding a food processor, a 1.12 oz container of Monarch Chopped Chives had no expiration date and no out date and a container of 26 oz Monarch steak seasoning, dated 7/1- no expiration date and no out date. In a large freezer in a room to the right of the DM's office and walk-in refrigerator, a package of ground up meat, not labeled or dated, package of brown round balls of meat were not labeled and not dated were found on a shelf. Bag of brown breaded food in large freezer was not labeled and not dated. In an observation on 08/24/2026 at 7:59 AM, three signs were posted on the front of the walk-in refrigerator door located next to the DM's office. One sign stated, Mandatory Reminder: 1. In and Out dates on food at all times. Second sign titled Food Dating Chart stated: spices- put received by date and use by date (2 years). Frozen foods: Put received by date and use by date (1-2 months). Put open date but since the product is frozen the use by date is unchanged. Third sign stated, Check all labels. Anything that you put in the walk-in needs to be dated. Cooks and Aids- check all temps every day. In an observation on 08/24/2026 at 11:57 AM, CNA F was observed touching personal clothing and hair/neck area and no hand hygiene practiced before delivering tray. In an observation on 08/24/2026 at 11:59 AM, CNA F was observed not practicing hand hygiene after delivering tray, touched hair/neck area, did not practice hand hygiene after touching, and left dining area to deliver a tray. In an observation on 08/24/2026 at 12:06 PM, CNA F touched pants, shirt, and glasses, delivered a tray, and no hand hygiene was completed. In an observation on 08/25/2026 at 8:28 AM, in a large freezer in a room to the right of the DM's office and walk-in refrigerator two boxes of Bomb Pop Nerds flavor, one box opened, not dated, second box unopened and not dated. A large clear bag of round cakes, not labeled, not dated, freezer burn was apparent and bag was torn. In an interview on 08/25/2026 at 9:45 AM, DA I stated the facility stopped using gloves and hand hygiene should be practiced between each tray. DA I stated the CNA's delivered the trays and in-services were completed on [name of electronic training site]. DA I stated to properly store and label food was to write the date received on the item, what the item was, and place it in front of the closed item if there was more than one available. DA I stated everyone was responsible to ensure proper storage and labeling. DA I was shown a picture that contained a bag of round cakes with no label, no date, and hole in the bag. DA I stated there was no name on it, no date on it, and it has a hole in it. DA I stated a negative outcome of not practicing hand hygiene would be residents could get sick. DA I stated a negative outcome for not storing or labelling food correctly would be freezer burn and residents could get sick using old food. In an observation on 08/25/2026 at 10:37 AM, DA H washed hands at the sink using only cold-water handle. Sign on right side of the sink stated, Wash your hands- 1. Wet your hands with warm running water. In an observation on 08/25/2026 at 11:02 AM, DA H touched a dirty rag and put on clear gloves without completing hand hygiene. In an interview on 08/25/2026 at 11:06 AM, DA H stated hand hygiene was to be practiced before and after gloving. DA H stated she was to wash hands with warm water. DA H stated hand hygiene was to be practiced before and after every tray delivered in the dining area. DA H stated she was unaware she was using cold water to practice hand hygiene. DA H stated a negative outcome would be residents could get very sick. In an interview on 08/25/2026 at 2:52 PM, CNA D stated an in-service was provided two to three weeks ago and was done every couple of months. CNA D stated ADON oversaw training. CNA D stated hand sanitizer was to be used after every tray and usually washed before and after. CNA D stated a negative outcome of not practicing hand hygiene would be infections, transferring sickness, and passing germs. In an interview on 08/25/2026 at 2:59 PM, CNA E stated they received an in-service on hand hygiene a month or two ago. CNA E stated they did a skill at the sink and was taught by [name of previous employee]. CNA E stated hand hygiene was to be practiced after each tray and going into resident's rooms. CNA E stated hand sanitizer and washing hands were the methods of hand hygiene before serving. CNA E stated a negative outcome of not practicing hand hygiene could be the spread of E-coli or maybe just dirty stuff like sickness and illness. In an interview on 08/25/2026 at 3:04 PM, CNA F stated they received training three months ago. CNA F stated hand hygiene was to be practiced after passing out trays and before you grab the next one with hand sanitizer. CNA F stated a negative outcome would be infections. In an interview on 08/25/2026 at 3:08 PM, RN G completed hand hygiene training during onboarding, and it was presented through an online learning center. RN G stated hand hygiene was to be practiced before serving, before a resident is approached or after the resident is served, and whenever hands were soiled. RN G stated hand sanitize after every tray or with any patient contact. RN G stated negative outcome would be sickness and infection. In an observation and interview on 08/25/2026 at 3:32 PM, the DM stated proper storage would be everything would go in a container and would have date made and expiration date. The DM stated she provided training throughout the week about labeling and dating items. The DM had a bag of pancakes in the sink and stated she did not see them in the freezer. The DM stated they were not labeled or dated and there was a hole in the bag. The DM stated hand hygiene was to be practiced when staff first starts and staff are to wash with hot water, not cold water. The DM stated ADON does training for hand hygiene. During the interview, DA B entered DM's office, located in the back of the kitchen, not wearing a hairnet. The DM stated staff were to put hairnets on before entering the kitchen and hairnets were supplied outside the kitchen entrance door. The DM identified staff member DA B as not wearing hairnet when entering the kitchen. The DM stated a negative outcome would be hair getting in the food. In an interview on 08/25/2026 at 3:42 PM, DA B stated was supposed to wear a hairnet before entering the kitchen. DA B stated a negative outcome would be hair in the food and cross contamination. In an interview on 08/26/2026 at 9:55 AM, the DON stated last staffing coordinator check off on hand hygiene training. The DON stated the ADON oversaw infection control. The DON stated hand hygiene was to be practiced before starting to pass trays or anytime when leaving dining room. The DON stated hand sanitizer was used for hand hygiene but if someone touched their face, they should wash their hands. The DON stated a negative outcome of not practicing hand hygiene would be infection control and the spread of germs. In an interview on 08/26/2026 at 10:15 AM, the ADON stated she did an infection control in-service, and it wasn't that long ago but did go over hand hygiene. The ADON stated hand hygiene should be practiced before or after any interaction, before picking up a tray, after done with the tray, after going to get coffee. The ADON stated a negative outcome of not practicing hand hygiene would be infection control. Record review of in-service over UTI/Bacteriuria- Clinical Protocol, dated 07/17/2026, listed an objective of the in-service as proper hand hygiene and was conducted by the ADON. Signature sheet revealed CNA F completed the training. Record review of document titled Opportunity- Improving Meal Service Quality and Resident Hand Hygiene Compliance, dated 07/24/2026, revealed a PIP stating an opportunity for improvement was identified during meal service observations regarding resident hand hygiene practices and meal service procedures. Observations revealed inconsistencies in ensuring residents' hands were cleaned prior to meals and in staff adherence to proper food service techniques. Providing appropriate hand hygiene before meals is essential in reducing the transmission of infection while promoting resident dignity, quality of life, and safe dining practices. Consistent meal service procedures also help ensure residents receive the correct diet, appropriate assistance, and a proper dining experience. Observations revealed inconsistencies in ensuring residents' hands were cleaned prior to meals and in staff adherence to proper food service techniques. Team members listed to meet weekly, beginning 07/01/2026, including the DON, The ADON, the DM, and the ADM. Record review of policy titled Handwashing/Hand Hygiene, dated 08/2019, under item 7, stated: b- before and after direct contact with the residents, f- before donning sterile gloves, o- before and after eating or handling food, and p- before and after assisting a resident with meals. Under heading washing hands, the policy revealed: 1. Wet hands first with water, then apply an amount of product recommend by the manufacturer to hands, 2. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers, 3. Rinse hands with water and dry thoroughly with a disposable towel, use towel to turn off the faucet, 4. Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis.Record review of policy Nutrition Policies and Procedures, subject Safe Food Handling, dated 08/01/2020, under heading General Statements, revealed on line 8: anyone working in the kitchen during normal food production hours is expected to wear appropriate hair restraints (such as hats, hair covers or nets, beard restraints). Under heading Food/Beverage Prepared with Patients or residents Individually or Groups, line item 1- all foods/beverages used with patients or residents in a therapy or activities program are purchased, stored, prepared, and served per facility guidelines. Line 3 stated all foods removed from the original packaging are stored in a closed container or tightly wrapped package and labeled with the common name of the item and the date it was opened.

Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 1 of 19 residents (Resident #23) reviewed for advanced directives. Resident #23's OOH-DNR was not correctly completed as Resident #23's second witness signature was signed on the attending physician line. The facility's failure to ensure the accuracy of a residents advanced directive such as a DNR could cause harm and goes against resident's wishes.Findings Included:Record review of Resident #23's face sheet, dated [DATE], revealed a [AGE] year-old woman who was admitted to the facility on [DATE]. Diagnoses included unspecified sequelae of cerebral infarction (chronic/residual conditions resulting from a stroke), acute kidney failure, senile degeneration of brain (progressive deterioration of brain cells and function), unspecified dementia (cognitive decline), and reduced mobility. Under box Advance Directives, the face sheet indicated the resident was a DNR. Record review of Resident #23's quarterly MDS, dated [DATE], revealed a BIMS score of 14 indicating Resident #23 was cognitively intact. Record review of Resident #23's care plan, dated [DATE], revealed a focus of The resident request code status of: DNR with an initiation date of [DATE], with a goal of status will be maintained over next 90 days with an initiation date of [DATE] with a target date of [DATE]. Record review of Resident #23's OOH-DNR, with two dates of [DATE] and [DATE], revealed witness 2, [name of witness], signed in the attending physician's signature area of the form stating, All person who have signed above must sign below, acknowledging that this document has been properly completed. In an interview on [DATE] at 9:23 AM, LVN C stated DNR's were in the computer. LVN C stated an accurate OOH-DNR form was signed by a doctor, family members agreed to it, POA, signature from one of them. LVN C stated sometimes the social worker oversaw advanced directives and would be told a resident needs a DNR. LVC C reviewed Resident #23's DNR and stated if signatures were not in the right place, it would be inaccurate. LVN C stated the second witness signed in the wrong place. LVN C stated a negative outcome of not having an accurate DNR would be they would be a full code when they were a do not resuscitate. In an interview on [DATE] at 2:52 PM, CNA D stated a resident's advance directive status was found on the EMR [name of specific section] but can be found by the resident's name. CNA D stated they do not look at the residents advance directive status and stated they did not know a negative outcome for someone who has an inaccurate DNR in the system. In an interview on [DATE] at 2:59 PM, CNA E stated a resident's code status was in [name of section] in the EMR and nurses oversaw the DNR's. CNA E stated a negative outcome of not having an accurate DNR would be the resident could be resuscitated. In an interview on [DATE] at 3:04 PM, CNA F stated a resident's code status would be in their health chart. CNA F stated they didn't know who oversaw advanced directives. CNA F stated a negative outcome of a resident not having an accurate DNR would be they might not get the help that they need. In an interview on [DATE] at 3:08 PM, RN G stated the SW oversaw the DNR's. RN G stated a resident's code status could be found on the EMR as it was required upon admission. RN G stated they would have to ask the administrator what would happen if the DNR was not correct. RN G reviewed Resident #23's OOH-DNR form and stated the second witness signature was in the wrong place and it makes the DNR invalid. RN G stated a negative outcome of a resident having an inaccurate DNR was the resident would be resuscitated and it would go against their wishes. If the resident was wishing to be a DNR, she would be devastated if brought back. In an interview on [DATE] at 9:47 AM, the SW stated last training was on [name of education website]. The SW stated from time-to-time in-services were provided to staff. The SW stated the advance directive status should be when chart was opened and should state a full code or a DNR. The SW stated they go through all the advance directives every month to ensure they were accurate. The SW stated she knew which DNR was inaccurate and the witness signed at the top part, not the very bottom. The SW stated she printed the DNR form and took it to the person for them to sign the bottom and it was fixed on the spot. The SW did identify the second witness signed on the attending physician's line and the form was still inaccurate, and the witness should have signed on the witness 2 line. The SW stated a negative outcome of not having an accurate DNR would be the resident would be turned into a full code if it was not accurate or valid. In an interview on [DATE] at 9:55 AM, the DON stated the SW oversaw all advance directives and it was in [name of electronic medical record system]. The DON reviewed Resident #23's corrected OOH-DNR and stated that one of the witnesses signed on the attending physician's signature. The DON stated the OOH-DNR was inaccurate with the witness' name still being on the attending physician's signature. The DON reviewed Resident #23's OOH-DNR prior to the corrected form and stated the OOH-DNR was not accurate, and the witness should have signed under the 2nd witness area. The DON stated a negative outcome of not having an accurate DNR would be the facility would have to do CPR and that goes against the resident's wishes. In an interview on [DATE] at 10:15 AM, the ADON stated the SW oversaw advanced directives and did not know when the last in-service was. The ADON reviewed Resident #23's OOH-DNR form and identified one of the witnesses' signatures was located by the attending physician's signature because the doctor's signature is beside the witnesses' signed name. The ADON stated the OOH-DNR was not accurate with the witness's name still presented on the attending physician's signature line. The ADON reviewed original OOH-DNR form for Resident #23 and stated the OOH-DNR was inaccurate as the witness should have signed by the 2nd witness line. The ADON stated a negative outcome of a resident not having a valid OOH-DNR for would be the facility could save their life and that was not what was wanted. Record review of facility policy, Advance Directives, dated 09/2022, stated the policy statement of the resident had the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives were honored in accordance with state law and facility policy. Record review of website, Texas Health and Human Services Out of Hospital No Not Resuscitate Program, dated 2026, under Frequently Asked Questions, stated the statute requires that everyone who signed the form MUST sign the form again in the bottom section to acknowledge that the form has been completed. Record review of OOH-DNR form, undated, revealed in the last section of the form that All persons who have signed above must sign below, acknowledging that this document has bene properly completed. The form contained seven signature lines and included person's signature, guardian/agent/proxy, relative signature, attending physician's signature, second physician's signature, witness 1 signature, witness 2 signature, and notary's signature.

Based on observation, interview and record review, the facility failed to ensure that the resident's environment remained as free from accident hazards as possible and that each resident received adequate supervision to prevent accidents for 1 (Resident #23) of 19 residents reviewed for accident hazards. The facility failed to ensure smoking materials were secured as Resident #23 had a vape (electronic cigarette) in her possession while in her room. This failure could place residents at risk for allergic reactions, difficulty breathing, and fire hazards.Findings included:Record review of Resident #23's face sheet, dated 08/24/2026, revealed a [AGE] year-old woman who was admitted to the facility on [DATE]. Diagnoses included unspecified sequelae of cerebral infarction (chronic/residual conditions resulting from a stroke), acute kidney failure, senile degeneration of brain (progressive deterioration of brain cells and function), unspecified dementia (cognitive decline), and reduced mobility. Record review of Resident #23's quarterly MDS, dated [DATE], revealed a BIMS score of 14 indicating Resident #23 was cognitively intact. Record review of Resident #23's care plan, dated 08/05/2026, revealed a focus of The resident was a smoker, with a goal of the resident will not smoke without supervision through the review date, and interventions that included instructing resident of the facility policy on smoking: locations, times, safety concerns, notifying charge nurse immediately if it was suspected resident has violated facility smoking policy, the resident requiring supervision while smoking, and the resident's smoking supplies are stored at nurses desk. Record review of Resident #23's smoking-safety screening, dated 07/24/2026, revealed Resident #23 does not have cognitive loss, no vision defects, smoked 5-10 cigarettes a day, smoked mornings, afternoons, and nights, resident could not light their own cigarette, and resident required supervision. Line 7e stated resident also used a vape. Line 8 stated resident needed facility to store lighter and cigarettes. Under heading IDTC Decision, it was noted that resident always required supervision and were safe to smoke with supervision. Record review of facility list of smokers, date unknown, revealed Resident #23 was a smoker. Record review of facility admission packet, not dated, revealed a smoking policy that stated it was the policy of the facility to provide a smoke-free environment for residents and staff. Smoking occurred in designated areas that are environmentally separate from all resident care areas. These designated locations may be outdoors. Staff maintained/kept all smoking materials (e.g., cigarettes, pipes, matches, lighters, lighter fluid) and distributed the materials to residents at smoking times. The policy included on page 20 which had a signature box for the resident as well as the facility representative which included the statement, I have read, understand, and would abide by the facility's Smoking Policy. The document was signed by HR and Resident #23 on 04/10/2026. In an observation on 08/25/2026 at 8:28 AM, Resident #23 had a yellow vape (electronic cigarette) lying on her bed by her remote and headphones. In an interview on 08/25/2026 at 9:23 AM, LVN C stated residents were not allowed to have smoking materials in their room. LVN C stated that lighters, cigarettes, vapes and all smoking materials were kept locked at the nursing station. LVN C was shown a picture of a vape, remote control, bed control, top right corner of a bedside table with glass of orange juice and one earpiece to a set of headphones on a blanket with various colored flowers. LVN C identified a vape. LVN C stated vapes were not allowed in rooms and it was everyone's responsibility to make sure smoking materials were locked up. LVN C stated a negative outcome would be residents that have respiratory problems don't want to be around that (vaping), it could cause a fire, and someone could get burns. In an interview on 08/25/2026 at 2:52 PM, CNA D stated the facility's smoking policy was for residents to go out at their smoke time, staff takes cigarettes, lights 2 cigarettes for each resident, and sits outside while residents smoke. CNA D stated residents were not allowed to keep smoking items in their room and all smoking materials, including vapes, were to be locked up at the nurse's station. CNA D reviewed a picture of a vape, remote control, bed control, top right corner of a bedside table with glass of orange juice and one earpiece to a set of headphones on a blanket with various colored flowers. CNA D identified a vape and stated that it was Resident #23's blanket in the picture. CNA D stated it was noticed that resident wasn't getting up to go out and smoke over the last week. CNA D stated the vape was not allowed in the resident's room. CNA D stated a negative outcome would be people that were on oxygen would cough. In an interview on 08/25/2026 at 2:59 PM, CNA E stated the facility's smoking policy was every two hours, two cigarettes for each person and we sit out there with them. CNA E stated residents were not allowed to keep smoking items in their rooms. CNA E was shown a picture of a vape, remote control, bed control, top right corner of a bedside table with glass of orange juice and one earpiece to a set of headphones on a blanket with various colored flowers. CNA E identified a vape. CNA E identified it was Resident #23's room and Resident #23 should not have the vape in their room. CNA E stated a negative outcome would be someone with COPD could be sharing a room, or the person who smokes would have lung problems. It would also cause problems with the residents who don't smoke or cause a fire. In an interview on 08/25/2026 at 3:08 PM, CNA F stated the facility's smoking policy was to take residents out on the timed schedule which was posted by the dining room door. CNA F stated residents were not allowed to keep smoking materials in their room. CNA F was shown a picture of a vape, remote control, bed control, top right corner of a bedside table with glass of orange juice and one earpiece to a set of headphones on a blanket with various colored flowers. CNA F identified a vape in the picture. CNA F stated the vape was not allowed in the room and vapes were kept at the nurse's station. CNA F stated a negative outcome would be a fire. In an interview on 08/25/2026 at 3:08 PM, RN G stated the facility's smoking policy was residents were allowed 3 smoking breaks, 2 cigarettes, they were not allowed to share cigarettes, and someone must go with the residents. RN G stated residents were not allowed to have smoking materials in their room. RN G was shown a picture of a vape, remote control, bed control, top right corner of a bedside table with glass of orange juice and one earpiece to a set of headphones on a blanket with various colored flowers. RN G identified a vape. RN G stated residents were not allowed to have the vape in their room, it has to be controlled and was to be locked up at the nurse's station. RN G stated a negative outcome would be a fire hazard or the resident could overdose on nicotine. In an interview on 08/26/2026 at 9:55 AM, the DON stated the facility's smoking policy stated smoking was allowed in designated smoking areas and that all smoking materials were to be left with the nurses and residents were to be supervised. The DON was shown a picture of a vape, remote control, bed control, top right corner of a bedside table with glass of orange juice and one earpiece to a set of headphones on a blanket with various colored flowers and identified a vape. The DON stated the vape was not allowed to be in the rooms and a negative outcome would be an injury. In an interview on 08/26/2026 at 10:15 AM, the ADON stated the facility's smoking policy was whatever the times were and someone had to be out with the residents. The ADON stated residents were not allowed to keep any smoking materials and they should be locked up in the medication room. The ADON was shown a picture of a vape, remote control, bed control, top right corner of a bedside table with glass of orange juice and one earpiece to a set of headphones on a blanket with various colored flowers. The ADON identified the vape in the picture and stated it was not allowed to be in the resident's room. The ADON stated a negative outcome would be the resident could overdose on nicotine and if someone has an allergy they get it. Record review of Smoking Policy-Residents, dated 08/2022, revealed residents are informed of the facility smoking policy including designated smoking areas, which were located outside of the building. Resident smoking status was evaluated including method of tobacco consumption (traditional cigarettes, electronic cigarettes, pipes, etc). Line 14 stated residents without independent smoking privileges could not have or keep any smoking items, including cigarettes, tobacco, etc., except under direct supervision. Under heading Electronic Cigarettes, line 2 stated to prevent accidents associated with e-cigarettes and to respect the rights of residents who did not want to be exposed to second-hand aerosol, residents are permitted to use e-cigarettes with supervision and in designated smoking areas only.Record review of Resident Smoking Policy, dated 09/01/2011, stated the facility was a smoke-free environment. There are no designated smoking areas in the building. Residents wishing to smoke during their stay will be permitted to do so only with staff supervision and only in designated areas. Smoking is strictly prohibited in any other area of the facility and/or its property, without exception. Supervision stated facility staff will distribute and ignite all smoking materials and will remain in the designated smoking area. Resident smoking policy also stated that any smoking materials [NAME] into the facility for a resident's future use must be given directly to facility staff for handling. All residents are prohibited from keeping any type of smoking materials in their rooms or on their person. Smoking is prohibited in any area where oxygen is in use. The policy included page 20 which had a signature box for the resident as well as the facility representative which included the statement, I have read, understand, and will abide by the facility's Smoking Policy.

Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided with such care consistent with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for respiratory care. The facility failed to store Resident #1's nasal cannula properly. Resident #1's nasal cannula was left on the floor for 4 hours. This failure could place resident at risk for complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition.Findings included: Record review of the face sheet printed 7/21/26 for Resident #1 revealed a [AGE] year-old female resident admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include chronic respiratory failure (a long-term condition that occurs when the body's respiratory system can't exchange oxygen and carbon dioxide properly), hypoxia (a condition where there is an inadequate supply of oxygen to the body's tissue), end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant), chronic congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), pneumonia (5/08/26) (lung inflammation caused by a bacterial or viral infection), and muscle weakness. Record review of Resident #1's quarterly MDS assessment completed 5/12/26 listed her with a BIMS of 12 indicating she was moderately cognitively impaired, she had a functionality of requiring partial/moderate assistance with her upper and lower body mobility, and she required oxygen therapy. Record review of Resident #1's comprehensive care plan with admission date 3/20/26 revealed Resident #1 was listed for oxygen therapy in 6 of her 27 focus care areas to include the following: The resident has oxygen therapy r/t SOB. Date Initiated: 11/06/24. Record review of Resident #1's Order Summary Report with Active Orders As Of: 7/21/26 revealed the following order: May use oxygen @ 2 L per NC to maintain sats @ =/> 90% and/or SOB. every shift for SOB. Active 10/24/24. During an observation and interview on 7/21/26 at 09:30 AM Resident #1 was not in her room. Observed was Resident #1's oxygen tubing stored over her left bedrails with the nasal cannula hanging on the floor next to the bed and the nasal prongs touching the surface of the floor. Resident #1 was observed sitting at the front door of the facility looking at her phone. Resident #1 was observed wearing O2 via nasal cannula from an oxygen bottle that was attached to the back of her wheelchair. Resident #1 reported good care, and she had no issues with the staff. During an observation on 7/21/26 at 11:19 AM Resident #1's oxygen tubing was stored over her left bedrails with the nasal cannula hanging on the floor next to the bed and the nasal prongs were in direct contact with the floor's surface. During an observation on 7/21/26 at 11:44 AM Resident #1's oxygen tubing was stored over her left bedrails with the nasal cannula hanging on the floor next to the bed and the nasal prongs were in direct contact with the floor's surface. During an observation on 7/21/26 at 12:29 PM Resident #1's oxygen tubing was stored over her left bedrails with the nasal cannula hanging on the floor next to the bed and the nasal prongs were in direct contact with the floor's surface. During an observation on 7/21/26 at 12:58 PM Resident #1's oxygen tubing was stored over her left bedrails with the nasal cannula hanging on the floor next to the bed and the nasal prongs were in direct contact with the floor's surface. During an observation on 7/21/26 at 1:30 PM Resident #1's oxygen tubing was stored over her left bedrails with the nasal cannula hanging on the floor next to the bed and the nasal prongs were in direct contact with the floor's surface. During an interview on 7/21/26 at 1:16 PM CNA A (the CNA responsible for Resident #1 this shift) reported staff are to make rounds at a minimum every two hours. Staff should check the residents' oxygen to make sure it was stored correctly. Staff should make sure the nasal cannula and tubing are stored off the floor in a plastic bag on the back of the concentrator. CNA A reported if the nasal cannula was found on the floor they are to throw it away and get a new one. CNA A reported the DON has done all the training on how to store oxygen equipment and care and that she had been trained. During an interview on 7/21/26 at 1:26 PM the DON reported the CNA staff should make rounds every two hours, and they were supposed to check the resident's oxygen equipment and make sure the oxygen tubing was stored correctly which should be in a plastic bag off the floor. DON stated, If the residents oxygen tubing has been on the floor for 4 hours, then they have probably not gone in that room. DON reported that the nursing staff were supposed to check the CNA staff and ensure they were doing their duties. DON reported if a tubing was found on the floor it should be thrown away and replaced with new tubing. DON reported if not addressed correctly the resident could get an infection. During an interview on 7/21/26 at 1:43 PM LVN B reported the nurses attempt to make a complete round at least once a shift to assess all the residents, CNAs were supposed to make rounds every 2 hours, and the nurses were supposed to check the CNAs to ensure they were completing their duties. LVN B reported she noticed Resident #1's nasal cannula was on the floor when she was making rounds with the NP at approximately 1:30 and that she (LVN B) had replaced the nasal cannula. LVN C reported that if a nasal cannula was left on the floor and the resident reused the nasal cannula or a staff member placed the nasal cannula back on the resident, the resident could get an infection from the bacteria, because who know what urine or feces someone stepped in and carried to that floor. During an interview on 7/21/26 at 2:01 PM DON provided training for LVN B on respiratory distress and reported that CNA A did not have training that was specific for checking oxygen equipment. DON reported all training was provided online and they have training on infection control but nothing specific for the oxygen equipment. DON reported the administrator had just assigned all staff training for oxygen therapy to be completed online. Record review of the facility provided policy titled Oxygen Administration revised October 2010 revealed no information related to oxygen equipment storage. Record review of the facility provided policy titled Routine Resident Checks revised July 2013 revealed no information related to checking oxygen equipment or proper oxygen equipment storage.

Based on interviews and records reviews, the facility failed to permit 1 (Resident #1) of 1 resident reviewed for discharge, to remain in the facility and not transfer or discharge the resident from the facility.The facility discharged Resident #1 and did not allow Resident #1 to return to the facility after being denied admittance by an acute care facility on 06/06/2026.This failure could result in residents' needs not being met, decline in resident safety, and a violation of resident's rights.Findings Include: Record review of Resident #1's face sheet, dated 06/29/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnoses include but are not limited to anoxic brain injury (no oxygen to brain for a period long enough to damage brain cells), type 2 diabetes(body is resistant to insulin or when the pancreas fails to produce enough insulin), critical illness myopathy (generalized, symmetrical weakness of skeletal muscles), intermittent explosive disorder (sudden episodes of unwarranted anger), dysphagia (difficulty swallowing), attention-deficit hyperactivity disorder (neurodevelopmental disorder), generalized anxiety disorder (excessive incontrollable worry about every day issues), muscle wasting and atrophy (loss or thinning of muscle mass and strength), and cognitive communication deficit (disruption of mental processes essential for communication). Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS of 07 which indicated severe cognitive impairment, suggesting difficulties with memory, orientation, and thinking skills. Section D, Mood, revealed a total severity score of 0. Section GG-functional abilities- revealed resident was substantial/maximal assistance for eating, oral hygiene, toileting, shower/bathe self, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. Section GG- Mobility- revealed resident was substantial/max assist for toilet transfer, partial/moderate assistance with rolling left to right, and supervision or touch assistance with sit-to-lying, lying to sitting on side of bed, sit to stand, char/bed-to-chair transfer, tub/shower transfer, walk 10 feet, walk 50 feet with two turns, and walk 150 feet. Question Q5 revealed that Resident #1 does not use a wheelchair. Record review of Resident #1's discharge MDS, dated [DATE], revealed with question A0310, question F, that Resident #1 was discharged with return not anticipated. Review of question A0310, section G, revealed the type of discharge was unplanned. Question A2105 revealed code 07 for discharge status which indicated that Resident #1 was discharged to a psychiatric hospital or unit. Section E- Behavior, section E0200 revealed resident had behavior of this type occurred 1 to 3 days for physical behavioral symptoms directed towards others, verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed towards others. Record review of Resident #1's care plan, dated 06/11/2026, revealed a focus of The resident is physically aggressive combative r/t poor impulse control. Resident had an altercation with other resident that took his food; Resident #1 hit the resident; placed on one-to-one and IDT looking for psych hospital placement. Record review of progress note, dated 06/04/2026, revealed residents were heard screaming from the other side of the facility. Resident #1 was screaming and cursing nurses and other residents. Staff members attempted to de-escalate the situation and were able to redirect Resident #1 to his room where he began punching walls. Intervention was initiated and Resident #1 became calm while continuing one-to-one supervision. Record review of progress note, dated 06/05/2026, labeled as a behavioral note indicated that Resident # 1 remains on continuous supervision due to behavioral concerns. Nursing staff notified administration and nursing staff notified administration and local law enforcement after an incident in which the resident struck another resident with a door. Staff supervising resident attempted immediate intervention; however, the door made contact with the other resident's face before staff could prevent the incident. The facility stated they contacted law enforcement who attempted to assist with placement in an inpatient psychiatric facility due to Resident #1's escalating behaviors and several hospitals were contacted where Resident #1 was declined to be admitted . The facility was advised to contact law enforcement if Resident #1's behaviors continued to escalate. Record review of Resident #1's progress note, dated 06/06/2026, revealed the following note, Immediate transfer/discharge pursuant to 42 CFR 483.15(c)(1)(i)(C) due to resident's behavioral status endangering the safety of other residents and staff, Resident physically assaulted another resident and presents an ongoing risk for further harm. Transfer to [name of facility] at [name of local hospital] is necessary to ensure the health and safety of others and provide a more appropriate level of behavioral health care ADM is transporting the patient to [name of local hospital]. Record review of form SNF/NF to Hospital Transfer Form, dated 06/06/2026, revealed transfer to [local hospital named] due to behavioral symptoms (e.g. agitation, psychosis). Form was signed by DON on 06/06/2026 at 12:20 with date transferred to the hospital noted at 06/06/2026 at 12:25. On 06/29/2026 at 11:12 AM, an attempt to contact Resident #1's family members was made with no success. On 06/29/2026 at 11:48 AM, an attempt to speak with [name of behavioral hospital] was attempted with no success. On 06/29/2026 from 1:32 PM to 1:51 PM, a second attempt was made to speak with [name of behavioral hospital] with no success. In an interview on 06/29/2026 at 2:25 PM, the SW stated Resident #1 has not been seen or assessed since discharge by the facility. The SW stated she is unsure if Resident #1 can return. The SW stated she was unsure if Resident #1 had tried to return to the facility. The SW stated that it would be in the best interest for Resident #1 not to return to the facility because there may be triggers that cannot be prevented. When asked for a negative outcome of the resident not being able to return to the facility, the SW stated, I'm not sure, I can find out. In an interview on 06/29/2026 at 2:50 PM, ADON stated that more outbursts, screaming and cussing, and threatening was what led to Resident #1's involuntary discharge. The ADON stated it was the administrator and the doctor who decided if Resident #1 would be readmitted . The ADON stated it was a resident right to return after being discharged . The ADON stated Resident #1 agreed to be discharged to [name of behavioral unit]. The ADON stated she does not feel there were any interventions as Resident #1 was up walking around and fine one minute and then wasn't. In an interview on 06/29/2026 at 3:20 PM, OMB stated Resident #1 was admitted to [name of hospital]. In an interview on 06/29/2026 at 4:03 PM, the CM stated Resident #1 was admitted to [name of hospital] and that she has talked to the facility. The CM stated that Resident #1 was not a safe discharge. The CM stated that the FL stated the facility was not taking Resident #1 back. The CM stated that Resident #1 is very directable and behaviors are minimal. The CM stated Resident #1 would need to be placed on a locked unit. In an observation and interview on 06/29/2026 at 4:15 PM, Resident #1 was observed in a hospital room at [name of hospital]. Resident #1 stated he was kicked out but doesn't remember why he was kicked out. Resident # 1 stated he was ok with [name of facility] but is okay with going to another facility. In an interview on 06/29/2026 at 4:37 PM, the DON stated Resident #1's behaviors started on 06/03/2026 and Resident #1 was discharged on 06/06/2026. The DON stated the facility sent Resident #1 to the hospital, the [name of behavioral hospital] communicated with DON, at an undisclosed day/time, and stated [name of behavioral hospital] were putting Resident #1 on an Uber, and Resident #1 did not come back to the facility. The DON stated the [name of behavioral hospital] had sent Resident #1 to the [name of homeless shelter] instead of the facility. The DON stated local police sent Resident #1 to the hospital. The DON stated MD would not provide care because MD wouldn't take Resident #1 as a patient. The DON stated the facility has not looked at another physician to oversee Resident #1's care. The DON stated a negative outcome was hope the family would take care of him. In an interview via phone on 06/29/2026 at 4:51 PM, the ADM stated she knew Resident #1's agitation was getting worse. The ADM stated Resident #1 agreed to go to [name of behavioral unit]. The ADM stated the facility did do an immediate discharge due to assault on another resident and progression of verbal aggression. The ADM stated the resident has not been assessed after being discharged to return to the facility. ADM stated she knows Resident #1 doesn't belong at the facility. The ADM stated that corporate stated they cannot take him back. The ADM stated MD stated he was not accepting Resident #1 back as a patient. The ADM stated they felt they discharged him to a safe place. The ADM was made aware that the [name of behavioral health hospital] did not admit Resident #1 and they were sending him in a taxi back to the facility. The ADM stated Resident #1 did not return to the facility and was found at [ name of homeless shelter] by the police. The ADM stated the police took Resident #1 back to [name of hospital] where he was receiving treatment and medication until placement could be determined. Resident #1 was still admitted to [name of hospital]. The ADM stated a negative outcome would be that the resident must stay in the hospital until placement is found. In an interview on 06/30/2026 at 8:26 AM, FL stated CM called FL asking about discharge. FL stated he communicated about Resident #1's behaviors and discharge. FL stated he does not know if Resident #1 is allowed to return to the facility. In an interview on 06/30/2026 at 8:43 AM, CM stated FL told her that facility was not going to admit Resident #1 back in the facility. In an interview on 06/30/2026 at 8:52 AM, the ADON, DON, and FL were asked if [name of hospital] was to call and discharge Resident #1, would the facility admit. DON stated according to ADM and MD, no. ADON stated she understood Resident #1 was not going to be admitted . In an interview on 06/30/2026 at 9:13 AM, ADM stated if the [name of the hospital] was to send over records today and go through all the avenues, the facility would have to have all those items before the facility can safely say that Resident #1 can be here. Facility stated they can't do 1:1 as it is policy to not take residents back. The ADM stated the immediate discharge was to [name of behavioral unit]. The ADM confirmed they did provide the discharge due to Resident #1 assaulting another resident. The ADM stated MD can't take Resident #1 back as a patient. The ADM stated corporate was standing by to not readmit him because the facility was not able to safely meet his needs. ADM stated there shouldn't be a negative outcome as he was being discharged to a safe place that the facility was aware of which was what the facility did. The ADM stated there were no other aggressive residents in the facility. The ADM stated she was willing to take the tag because she truly felt that what was done was right. In an interview on 06/30/2026 at 10:40 AM, the ADM stated she believed Resident #1 was admitted to behavioral unit. Police called ADM and stated Resident #1 was not going to be allowed to stay at [name of behavioral unit]. ADM stated she did not offer to obtain Resident #1 from behavioral unit. In an interview on 06/30/2026 at 10:35 AM, CM stated called facility and texted with FL. CM asked if Resident #1 was discharged , would Resident #1 be allowed to return to the facility. FL replied with following statement, I'm sorry, but at this time I do not have a medical director with admitting privileges at this facility who is able to accept him due to the risk he may pose to the safety and well-being of our other patients. In an interview via phone on 06/30/2026 at 11:56 AM, the MD stated Resident #1 was a danger to self and other patients. The MD stated he fired him to protect the other residents. The MD stated if [name of hospital] was to call and state they are discharging; he would not readmit him. Record review of flyer titled Your Rights in a Nursing Facility, dated January 2025, stated under heading Transfers and Discharges, revealed a resident has the right to not be discharged from the facility, except in accordance with nursing facility regulations and be readmitted to the facility as provided by nursing facility regulations. Record review of procedure titled, Discharging the Resident, revised December 2016, revealed the purpose of the procedure is to provide guidelines for the discharge process. Facility did not provide a discharge or transfer policy as requested during entrance conference and documented wish list sent by email on 06/29/2026 at 8:27 AM.

Based on interview and record review the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #1) of 5 residents reviewed for advanced directives. Resident #1 had a DNR in her record that was not dated by the physician. The facility's failure could place residents at risk for not receiving healthcare as per their or their legal representatives' wishes.Findings included: Record review of Resident #1's face sheet printed 12/17/2025 revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), atherosclerotic heart disease of native coronary artery with unstable angina pectoris (narrowing and hardening of the arteries due to buildup of plaque) and an aneurysm of the ascending aorta, without rupture (weak spot on aorta). The face sheet reflected that Resident #1 had a Do Not Resuscitate (DNR) order under Advance Directives Record review of Resident #1's Quarterly MDS Assessment completed 10/29/2025 indicated a Brief Interview of Mental status (BIMS) score of 12, reflecting moderately impaired cognition, and documented that the resident required supervision or touching assistance with activities of daily living. Record Review of Resident #1's care plan, most recently revised on 10/29/2025, included the following problem statement: Resident had an order for Do Not Resuscitate. Date initiated: 07/11/2025 Resident had a terminal prognosis and was admitted to hospice dated 07/29/2025 Record review of the clinical record printed on 12/17/2025, revealed an order summary that listed: DNR- Active - 07/11/2025. Resident was admitted to Hospice on 7/17/2025.Record review of the electronic medical record revealed no DNR document uploaded or maintained in the system Record review of a paper DNR located at the nurses' station for Resident #1 revealed the DNR form was signed and dated by the resident and signed by two witnesses on 07/11/2025. Review further revealed the physician had signed the DNR; however, the signature was not dated. During an interview on 12/17/2025 at 7:45 AM, LVN A (the nurse responsible for Resident #1 this shift) reviewed the paper DNR and stated the document was incorrect because the physician had not dated the signature and the physician should be responsible for ensuring the DNR was completed correctly. During an interview on 12/17/2025 at 8:25 AM, the ADON reviewed the DNR and stated the document was not valid because the physician had not signed and dated it, and that honoring the DNR in its current state would be against the resident's' wishes. The ADON stated the SW was responsible for ensuring DNR documents were completed correctly. During an interview on 12/17/2025 at 8:40AM, the SW reviewed the DNR and said she was unsure whether the document was completed correctly. The SW stated she believed the form appeared acceptable but indicated she was not responsible for DNR completion and that responsibility belonged to the DON. During an interview on 12/17/2025 at 8:45 AM, the DON reviewed the DNR and stated the document was incomplete and not filled out correctly. The DON stated that, due to the incomplete DNR, the resident would need to be coded, which would be against the resident's expressed wishes.During an interview and observation on 12/17/2025 at 9:00 AM, Resident #1 was observed sitting in bed eating breakfast. The resident stated she was on hospice services and that her wish was to be a DNR.During an interview and observation on 12/17/2025 at 9:50AM, the SW and ADM presented a second DNR obtained from the hospice agency. Review of this document revealed it was signed and dated by Resident #1, and two witnesses on 07/15/2025, with RN and LVN written after the witness signatures and signed and dated by the physician on 07/16/2025. During the discussion the ADM stated that both witnesses were employed by the facility at the time the DNR was signed. After reviewing the DNR instructions, the ADM acknowledged the DNR was not valid because both witnesses were direct care staff at the time of execution. The ADM who was aware the SW was responsible for the DNRs stated she would get with SW and conduct an audit of all DNR documents.Record review of the facility provided policy titled Advanced Directives updated December 2016, revealed the following: Policy Statement: Advanced Directives will be respected in accordance with state law and facility policy.Record review of the OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES, revealed the following:-The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals.

Based on observation, interview, and record review the facility failed to review the risks and benefits of bed rails with 1 of 5 (Resident #1) residents or their resident representatives and obtain informed consent prior to installation of bed rails, in that:Resident #1 had (1) one-half length bed rail installed on the right side of her bed without a physician order, without documented informed consent from the resident or resident representative and without inclusion of bed rail use in the resident's comprehensive care plan. This failure placed the residents at risk for injury, including entrapment of bedrails, hindered the resident's' ability to independently exit the bed and could negatively impact the resident's' ability to engage in activities of daily living.Findings included:Record review of Resident #1's face sheet printed 12/17/2025 revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), atherosclerotic heart disease of native coronary artery with unstable angina pectoris (narrowing and hardening of the arteries due to buildup of plaque) and an aneurysm of the ascending aorta, without rupture (weak spot on aorta). Unspecified fracture of sacrum, subsequent encounter for fracture with routine healingRecord review of Resident #1's Quarterly MDS Assessment completed 10/29/2025 indicated a Brief Interview of Mental status (BIMS) score of 12, reflecting moderately impaired cognition, and documented that the resident required supervision or touching assistance with activities of daily living. Record review of Resident #1's care plan, most recently revised on 10/29/2025, did not have any documentation relating to bed rail use. Care plan also indicated resident was a high risk for falls, with a history of falls prior to admission.Record review of Resident #1's active physician orders on 12/17/2025 did not include a physician order authorizing bed rail use.Record review of Resident #1's electronic medical record under consents on 12/17/2025 did not include documented informed consent for bed rail use. Record review of Resident #1's Bed Rail Safety Review dated 12/10/2025 reflected the bed rails will promote mobility.During an interview and observation on 12/17/2025 at 7:45 AM, LVN A (the nurse responsible for Resident #1 this shift) was observed reviewing Resident #1's orders and did not find an order for bed rails and stated she was new and unsure if orders were required for bed rails.During an interview and observation on 12/17/2025 at 8:25 AM, the ADON reviewed Resident #1's electronic medical record and could not find an order or consent in the record and stated she would look through her paper files to see if it did not get put in the system. The ADON said a possible negative outcome for having bed rails without orders or consent could cause harm.During an interview on 12/17/2025 at 8:45 AM, the DON stated she was responsible for documenting the use of bedrails in the care plan but stated since there was no physician order for the bed rail it did not alert her to add it to the care plan. The DON stated a possible negative outcome for bed rail use without an order, informed consent, and care plan intervention could result in harm.During an interview and observation on 12/17/2025 at 9:00 AM, Resident #1 was observed sitting in bed watching tv, head of bed raised, she was eating breakfast. The Resident stated she liked the bed rail on her bed because it made her feel safe and helped with her mobility. During an interview on 12/17/2025 at 9:50AM, the ADON stated she could not find the consent and reported contacting the resident's representative to obtain consent. Record review of the facility's policy Proper Use of Side Rails dated December 2016 reflected the following: The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. The use of side rails as an assistive device will be addressed in the resident care plan Consent for the side rail use will be obtained from the resident or legal representative

Based on observation, interview, and record review the facility failed, in accordance with State and Federal laws, to store all drugs and biologicals in locked compartments for 1 (west wing medication cart) of 4 medication carts reviewed for medication storage.The facility failed to ensure RN locked the west wing medication cart when it was unattended.This failure could place residents at risk of injury due to ingesting non-prescribed medications and/or ingesting prescribed medications at incorrect doses or times.Findings included:During an observation on 12/01/2025 at 8:43am the west wing medication cart was unlocked and unattended. Unidentified residents were walking about freely around the medication cart.During an observation on 12/01/2025 at 8:45am the RN for the west wing of the facility came back to the medication cart and locked it.During an interview on 12/01/2025 at 8:49am RN stated the reason she did not lock the west wing medication cart was because she just forgot. RN stated that a negative outcome for the residents was They might take something out of it.During an interview on 12/01/2025 at 9:30am ADON stated that the negative outcome for not locking medication carts would be that other residents could get into the cart and take medications that were not theirs.During an interview on 12/01/2025 at 10:42am ADM stated that the negative outcome for residents getting into an unlocked medication cart would be that other residents could get into the cart and take medications that did not belong to them.Record review of facility policy titled Administering Medications, dated April 2019 revealed the following: . 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide.

Based on observations, interviews, and record reviews the facility failed to ensure the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 (Resident #2 and Resident #3) of 5 resident's reviewed for abuse.1. The facility failed to protect Resident #2 from mental and verbal abuse by Resident #3 when he threatened to cut off her foot with a hand saw and proceeded to saw a groove in the center of her top, front, walker bar.2. The facility failed to protect Resident #3 from neglect when he was able to obtain a hand saw from an unlocked maintenance closet.These failures could place residents at risk of abuse and neglect.An Immediate Jeopardy (IJ) was identified on 09/12/25. The IJ template was provided to the facility on [DATE] at 01:00 PM. While the IJ was removed on 09/13/25 at 12:08 PM the facility remained out of compliance at a severity level of no actual harm potential for more than minimal harm not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. Plan of Removal of IJ will be included in findings.Findings Included:1. Record review of Resident #2's admission record dated 09/11/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) with late onset, intermittent explosive disorder (repeated sudden outbursts of anger), psychotic disorder with delusions (severe mental illness including distorted beliefs) due to known physiological condition, and major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities).Record review of Resident #2's admission MDS completed on 06/19/25 revealed a BIMS score of 10 which indicated moderately impaired cognition. Section GG Functional Abilities revealed Resident #2 used a walker. She was noted to require partial/moderate assistance to supervision/touching assistance across all ADLs. Record review of Resident #2's care plan initiated on 06/20/25 revealed she had the potential to be verbally aggressive and yell at other residents and staff related to dementia. Resident #2 was noted to receive antianxiety medication and antipsychotic medication.Record review of Resident #2's active orders revealed the following orders with corresponding start dates:07/30/25 risperiDONE Oral Tablet 0.25 MG (Risperidone) Give1 tablet by mouth at bedtime related to PSYCHOTICDISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION06/11/25 traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime for Headache related to MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES09/11/25 Vistaril Oral Capsule 50 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth every 04 hours as needed for anxiety for 14 Days2. Record review of Resident #3's admission record revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Parkinson's disease (chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement) without dyskinesia (abnormality or impairment of voluntary movement), unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), muscle wasting and atrophy (shrinkage or wasting away of tissue), muscle weakness, and other lack of coordination.Record review of Resident #3's quarterly MDS completed 09/05/25 revealed a BIMS score of 12 which indicated moderately impaired cognition. Section E Behavior revealed Resident #3 had no behaviors. Section GG Functional Abilities revealed he was independent across all ADLs. Section M Medications revealed he was receiving antidepressant, antiplatelet, and anticonvulsant medication.Record review of Resident #3's care plan completed on 09/08/25 revealed he was resistive to care r/t impaired cognition and he had potential to be physically aggressive throwing objects r/t behaviors. Resident #3 was noted to have potential to be verbally aggressive very rude and demanding r/t cognitive impairment. He had impaired cognitive function r/t dementia. He had a mood problem r/t MDD and declines to see psych. Interventions included administering medications as ordered, explain all procedures and orders prior to starting and allow time to adjust to changes, discuss inappropriate behaviors with resident when reasonable, monitor behavior episodes and attempt to determine underlying causes, and document behaviors and potential causes. Staff were instructed to give the resident 5-10 minutes when resistive to care before trying again and when he became agitated to intervene before the agitation escalated and guide him away from the source of distress. Staff were instructed to engage him calmly in conversation and if he became aggressive they were to walk calmly away and approach at a later time.Record review of Resident #3's active orders dated 09/11/25 revealed the following orders with corresponding start dates:05/18/25 Aspirin EC Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for Pain -Moderate11/20/24 Carbidopa-Levodopa Oral Tablet 25-250 MG(Carbidopa-Levodopa) Give 1 tablet by mouth five times a day related to PARKINSON'S DISEASE WITHOUT DYSKINESIA, WITHOUT MENTION OF FLUCTUATIONS09/03/25 clonazePAM Oral Tablet 0.5 MG (Clonazepam) Give 1 tablet by mouth three times a day related to ANXIETY DISORDER, UNSPECIFIED03/15/25 DULoxetine HCl Oral Capsule Delayed Release Sprinkle 30 MG (Duloxetine HCl) Give 1 capsule by mouth in the afternoon for dep03/14/25 DULoxetine HCl Oral Capsule Delayed Release Sprinkle 30 MG (Duloxetine HCl) Give 2 capsule by mouth at bedtime for dep related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED07/30/25 Mirtazapine Oral Tablet 30 MG (Mirtazapine) Give 1 tablet by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED09/10/25 Vistaril Oral Capsule 50 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth every 04 hours as needed for anxiety for 14 DaysRecord review of a referral order dated 09/10/25 revealed Resident #3 was being referred for Psychiatric Medication Management and Psychotherapy and Counseling Services.Record review Resident #3's progress notes from 03/11/25 to 09/12/25 revealed no mention of physical or verbal aggression toward another resident.During an observation and interview on 09/11/25 at 08:23 AM Resident #2 stated a male resident had a saw yesterday and threatened to cut off her feet and then cut on her walker. She gestured to the top, front bar of her walker.During an observation and interview on 09/11/25 at 08:36 AM Resident #2 was seen leaving ADON's office and stated she told ADON about the man threatening to cut off her feet with a saw.During an observation and interview on 09/11/25 at 08:36 AM ADON stated she was just told by Resident #2 about Resident #3 threatening her with a saw on 09/10/25.During an observation and interview on 09/11/25 at 08:41 AM ADM stated Resident #3 had a hand saw on 09/10/25. She stated, He took it out of the maintenance room is the only thing we can figure out. ADM stated CNA A and CNA B were working at the time and took the saw away from Resident #3. When asked if he used the saw to threaten Resident #2 and/or cut on her walker, ADM shook her head and stated, What you are going to find out is [name of Resident #2] doesn't tell the truth.During an interview on 09/11/25 at 08:50 AM CNA A stated regarding Resident #3 on 09/10/25, I mean he did have a saw but as soon as we seen him, we took it from him. He was rolling with the saw down the hall. She stated she did not hear him threaten Resident #2 or see him using the saw on Resident #2's walker. She stated she was trained regularly on recognizing and reporting suspected abuse and neglect. She stated she was to report suspected abuse and neglect to ADM.During an interview on 09/11/25 at 08:51 AM CNA B stated Resident #3 had a saw on 09/10/25 and he was using the saw on Resident #2's walker. She stated, You can look at her walker. There is proof. CNA B stated Resident #3 got the saw from the maintenance office. She stated she reported the incident to ADM and ADON as soon as the saw was taken away from Resident #3 on 09/10/25. She stated she was trained regularly on reporting suspected abuse and neglect and she was to report to ADM.During an observation and interview on 09/11/25 at 09:00 AM Resident #3 was lying in bed in his room. He stated he had a saw yesterday (09/10/25) and he got the saw from the shop (here he gestured with his left hand in the direction of the hallway which housed the maintenance office). Resident #3 was asked if he threatened to cut off a Resident #2's feet with the saw and he answered, Foot. He stated he threatened to cut off her foot. When asked if he used the saw on the female resident's walker, he said he did. During an observation on 09/11/25 at 09:03 AM of Resident #2's top, front walker bar revealed a small, shallow groove approximately 1.5 centimeters in length and 2 millimeters in depth with jagged edges.During an observation and interview on 09/11/25 at 09:04 AM Resident #2 showed this surveyor where she was sitting in a recliner with next to the nurses' station when Resident #3 threatened to cut off her feet and then cut on the top, front bar of her walker. She stated, I got so scared!During an interview on 09/11/25 at 09:07 AM CNA K stated she was trained often on recognizing and reporting suspected abuse and neglect. She stated she was to report to her charge nurse or to ADM.During an interview on 09/11/25 at 09:08 AM HSK stated she was trained regularly on recognizing and reporting abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM.During an interview on 09/11/25 at 09:19 AM RN C stated she was trained regularly on recognizing and reporting abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM.During an interview on 09/11/25 at 01:57 PM LVN D stated she was trained regularly on recognizing and reporting abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM.During an interview on 09/11/25 at 02:35 PM ADON stated on 09/10/25 around 4 or 5 PM Resident #3 had a hand saw. She stated she did not see him with the saw she just heard about him having it. She stated she received a phone call from LVN J on 09/10/25. LVN J told ADON it was reported to her (LVN J) Resident #3 had a hand saw that afternoon.During an interview on 09/11/25 at 02:43 PM ADM stated she was in the building on 09/10/25 when Resident #3 had a hand saw. She stated she did not see him with the hand saw but CNA A and CNA B told her about taking the saw from Resident #3. During an interview on 09/11/25 at 04:23 PM LVN G stated Resident #3 had a hand saw and was cutting on the top, front bar of Resident #2's walker and making fun with everyone who was in the common area that he could saw through the walker. She stated she went to his side and asked him to put the saw down because it was not his. During an interview on 09/11/25 at 04:23 PM LVN G stated she was trained regularly on recognizing and reporting abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM.During an observation on 09/11/25 at 05:04 PM Resident #3 was wheeling himself into the front door after smoking in the courtyard. He had been in the courtyard with ADON but came back into the facility on his own.During an interview on 09/12/25 at 08:16 AM CNA H stated she was trained regularly on recognizing and reporting abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM.During an observation and interview on 09/12/25 at 12:38 PM Resident #2 was in her room with the door shut. She stated she was staying in her room to avoid Resident #3. She stated she traded the walker Resident #3 used the saw on for another walker. Resident #2 stated, I started crying when I talked to my [family member] about the sawing.On 09/12/25 at 01:00 PM ADM and ADON were notified that an Immediate Jeopardy had been identified, IJ templates were provided, and Plan of Removal was requested.During an observation on 09/12/25 at 02:04 PM Resident #3 wheeled himself out the front door of the facility.During an interview on 09/12/25 at 03:27 PM Resident #2's family member stated Resident #2 called her last night (09/11/25) and told her about a male resident threatening to cut off her feet with a saw. She stated Resident #2 started bawling and crying while telling her about the incident. Resident #2's family member stated, [Resident #2] got scared. She (Resident #2) told me, 'Listen to me, listen to me, I'm scared of this man.'During an observation and interview on 09/12/25 at 3:43 PM SW showed this surveyor psychosocial evaluations done on Resident #2 and Resident #3 on 09/12/25. She stated both residents seemed fine and calm today. SW stated Resident #2 said she was not anxious or afraid.During an interview on 09/12/25 at 04:29 PM MD stated of Resident #3, I believe he has had some behavioral issues, but I don't know to the full extent of them.The facility's Plan of Removal (as follows) was accepted on 09/12/25 at 08:12 PM.Plan of RemovalProblem: There is a need for immediate action due to the break in the facility's risk management process regarding abuse, neglect, and elopement. Specifically, the facility staff will need to address corrective action to prevent future incidents of elopement from occurring in the facility, especially when residents are exhibiting signs and symptoms of elopement. All residents who are high risk for elopement are at risk of the alleged defected deficiency.F600Resident obtained the hand saw due to the maintenance office being locked [sic]. The facility was neglectful in leaving the door unlocked. This has been addressed for the future by installing a self-locking door knob [sic]. This will ensure that no one can get into the maintenance office unauthorized again and removes the potential for future neglect or harm.All staff were re-educated on the facility's policies and procedures related to abuse & neglect.Staff directly involved in the incident received targeted retraining focused on compliance, resident rights, and recognition/prevention of neglect and abuse. Interventions: The administrator notified the medical director of Immediate Jeopardy 9/12/25 & Ad HOC completed on 8/22/2025. The following in-services were provided:o On 8/21/25 DON/ADON provided education to staff on Dementia Care: Mental Decline, elopement policy & exit seeking protocol, and wandering/elopement education prior to their next working shift.o On 8/21/25 DON/ADON provided education to charge nurses on wandering/elopement, dementia care: Mental Decline, elopement policy and exit seeking protocol prior to their next working shift.o All staff will be educated by DON/ADON prior to working their next shift with a completion date of 8/21/25. All NEW staff will be educated prior to working their first shift.o On 8/22/25 Admin and DON/ADON provided education to staff on how to identify residents at risk/high risk. DON/ADON completed audit on 8/21/25 to ensure Elopement Assessments have been completed according to protocol. Charge Nurses will complete an Elopement Risk Assessment quarterly, upon admit, and for exit seeking behaviors. The assessment will provide a score to indicate if they are at risk or high risk for elopement. ADMIN/DON will be responsible for ensuring a resident has 1:1 supervision when required and will monitor that it is being followed. For residents who score at risk/high risk for elopement on the elopement assessment, a shoe emblem will be placed above the name plaque for A bed and below the name plaque for B bed to help staff identify residents at risk/high risk for elopement. Charge nurses will be responsible for ensuring there is not a lapse in 1:1 during shift change and that the oncoming staff are aware of exit seeking behaviors from the prior shift. Charge nurse removed hand saw immediately. No harm to either resident. Charge nurse administered medication per doctors [sic] order and referral obtained for a psych consult. Automatic lock placed on maintenance door. Inservice started on hazardous areas, devices and equipment and to ensure these doors stay locked. Maintenance staff in serviced on keeping office door locked to ensure hazardous equipment is not [sic] accessible to residents. Psychosocial assessment completed on both residents. Care plans have been updated on both residents. DON/designee will review 5 random resident care plans weekly x 8 weeks to ensure safety risks are addresses. Adminiswtrator [sic] will audit all incident/accident logs weekly to ensure corrective action and follow-ups are completed. Results will be reported monthly to QAPI committee for review and trend analysis.Inservices [sic] began 9/12/25 and all staff to be inserviced [sic] prior to beginning shift.Monitoring the Plan of Removal (POR) included:On 09/13/25 record review revealed the in-services, Ad HOC meeting (on 09/12/25), physician and family notifications, care plan updates, psychosocial assessments on Residents #2 and #3 (dated 09/12/25 and showing no issues for either resident), order for antianxiety medication for Resident #3 (dated 09/10/25) facility incident report to state (dated 09/12/25), posting of abuse policy, referral for psych services for Resident #3(dated 09/10/25) and starting of Q-15 minute checks on Resident #3 were completed.Interview with ADM, DON, and ADON on 09/13/25 at 11:00 AM revealed all facility staff had received the in-services started on 09/12/25 regarding elopement and accidents/hazards. ADM stated ADON had been calling staff who were not in the building and following the calls by sending an email copy of the in-service. ADM and DON stated they had been trained by their corporate representatives on investigation and reporting of suspected abuse/neglect.Record review of the in-services provided to ADM and DON on 02/06/25 revealed they were trained on the definition of abuse, abuse policies and procedures, freedom from abuse, resident rights, behavior intervention and crisis, abuse prevention, injury of unknown origin, and reporting.Record review of the in-service provided to staff by corporate on 09/12/25 revealed staff were trained on proper reporting and timely report, abuse policies and procedures including abuse definitions, freedom from abuse, resident rights, behavior interventions, behavior crisis, abuse prevention, injury of unknown source, thorough investigations for abuse and neglect and injury of unknown source, reporting of allegations of abuse to state and corporate, and reporting of allegations of abuse, neglect, and injury of unknown source to state.Record review of in-service provided to staff on 09/12/25 by ADON revealed staff were trained on Safe Storage, Random check to ensure maintenance doors are locked, Abuse/Neglect/Exploitation reviewed/posted, Investigating and reporting Incidents/Accidents, Appropriate assessments/interventions, Resident Rights.During an interview on 09/13/25 at 11:14 AM DA stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained yesterday on recognizing if a resident was attempting to elope and intervening as necessary. DA stated she was trained on keeping hazardous items out of reach of residents and in locked compartments. During an interview on 09/13/25 at 11:16 AM LVN D stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on keeping hazardous items locked and out of resident reach and on recognizing residents at risk of elopement.During an interview on 09/13/25 at 11:18 AM CNA I stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on keeping hazardous items locked and out of resident reach and on recognizing residents at risk of elopement. CNA I stated she was trained to keep wipes and cleaning solutions locked in the cabinet or in the shower room and she was trained on her part if a resident was missing from the facility to include searching her unit and counting the residents on her unit.During an interview on 09/13/25 at 11:23 AM CNA B stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on her part if a resident eloped from the facility as well as on keeping hazardous items out of reach of residents.During an interview on 09/13/25 at 11:24 AM RN SUP stated she was trained today (09/13/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. RN SUP stated she has been trained on her responsibilities regarding reviewing incident accident reports and 24-hour report on the weekends. She stated she was trained on her part if an elopement took place and on keeping hazardous items out of reach of residents.During an interview on 09/13/25 at 11:27 AM [NAME] stated she was trained today (09/13/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on recognizing if a resident was trying to elope and on how to intervene. [NAME] stated she was trained on keeping hazardous items out of reach of residents.During an interview on 09/13/25 at 11:29 AM CNA H stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on keeping hazardous items out of reach of residents and locked in appropriate cabinets or rooms and on her part if a resident attempted or succeeded in eloping.During an interview on 09/13/25 at 11:32 AM CNA F stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on keeping dangerous items locked up and out of reach of residents. She stated she was trained on her part if an elopement occurred.During an interview on 09/13/25 at 11:35 AM RN C stated she was trained yesterday (09/12/25) and today (09/13/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. RN C stated she was trained on her part if a resident attempted or succeeded in eloping and she was trained on keeping hazardous items locked up and out of reach of residents.During an observation on 09/13/25 at 11:40 AM ADM demonstrated the new self-locking doorknob on the maintenance office by unlocking it with a key and closing the door again. It was locked. The new doorknob was smooth on the inside of the door with no locking or unlocking mechanism aside from the keyhole on the outside of the door.Record review on 09/13/25 of Resident #3's revised care plan revealed a note regarding the incident on 09/10/25 with the handsaw. Interventions included Q 15-minute checks as indicated and documenting any signs or symptoms of resident posing a danger to himself or others. Staff were to ensure the maintenance office door was locked at all times.Record review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program and dated April 2021 revealed the following: .The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents; c. consultants; d. volunteers; e. staff from other agencies; f. family members; g. legal representatives; h. friends; i. visitors; and/or j. any other individual. 2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; b. neglect of residents; and/or c. theft, exploitation or misappropriation of resident property. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements. 10. Protect residents from any further harm during investigations.Record review of facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating and dated April 2021 revealed the following: . All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for detem1ining what actions (if any) are needed for the protection of residents. Investigating Allegations 1. All allegations are thoroughly investigated. The administrator initiates investigations. 2. Investigations may be assigned to an individual trained in reviewing, investigating and reporting such allegations. 3. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. a. Any evidence that may be needed for a criminal investigation is sealed, labeled and protected from tampering or destruction. 4. The administrator is responsible for keeping the resident and his/her representative (sponsor) informed of the progress of the investigation. 5. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. 7. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have bad contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members, and visitors; j. interviews other residents to whom the accused employee provides care or services; k. reviews all events leading up to the alleged incident; and I. documents the investigation completely and thoroughly.On 09/13/25 at 12:08 PM ADM, DON, and ADON were informed the IJ was removed as of 12:08 PM. An IJ was identified on 09/12/25. The IJ template was provided to the facility on [DATE] at 01:00 PM. While the IJ was removed, the facility remained out of compliance at a level of no actual harm potential for more than minimal harm not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observations, interviews, and record reviews the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 (Resident #2 and Resident #3) of 5 residents reviewed for abuse/neglect policy implementation.The facility failed to implement their abuse policy when Resident #3 obtained a hand saw from an unlocked maintenance closet and used it to threaten Resident #2 and to saw a groove into the top, front bar of Resident #2's walker.This failure could place residents at risk of abuse and neglect occurring and/or continuing.An Immediate Jeopardy (IJ) was identified on 09/12/25. The IJ template was provided to the facility on [DATE] at 01:00 PM. While the IJ was removed on 09/13/25 at 12:08 PM the facility remained out of compliance at a severity level of no actual harm potential for more than minimal harm not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. Plan of Removal of IJ will be included in findings.Findings Included:1. Record review of Resident #2's admission record dated 09/11/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) with late onset, intermittent explosive disorder (repeated sudden outbursts of anger), psychotic disorder with delusions (severe mental illness including distorted beliefs) due to known physiological condition, and major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities).Record review of Resident #2's admission MDS completed on 06/19/25 revealed a BIMS score of 10 which indicated moderately impaired cognition. Section GG Functional Abilities revealed Resident #2 used a walker. She was noted to require partial/moderate assistance to supervision/touching assistance across all ADLs. Record review of Resident #2's care plan initiated on 06/20/25 revealed she had the potential to be verbally aggressive and yell at other residents and staff related to dementia. Resident #2 was noted to receive antianxiety medication and antipsychotic medication.Record review of Resident #2's active orders revealed the following orders with corresponding start dates:07/30/25 risperiDONE Oral Tablet 0.25 MG (Risperidone) Give1 tablet by mouth at bedtime related to PSYCHOTICDISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION06/11/25 traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime for Headache related to MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES09/11/25 Vistaril Oral Capsule 50 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth every 04 hours as needed for anxiety for 14 Days2. Record review of Resident #3's admission record revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Parkinson's disease (chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement) without dyskinesia (abnormality or impairment of voluntary movement), unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), muscle wasting and atrophy, muscle weakness, and other lack of coordination.Record review of Resident #3's quarterly MDS completed 09/05/25 revealed a BIMS score of 12 which indicated moderately impaired cognition. Section E Behavior revealed Resident #3 had no behaviors. Section GG Functional Abilities revealed he was independent across all ADLs. Section M Medications revealed he was receiving antidepressant, antiplatelet, and anticonvulsant medication.Record review of Resident #3's care plan completed on 09/08/25 revealed he was resistive to care r/t impaired cognition and he had potential to be physically aggressive throwing objects r/t behaviors. Resident #3 was noted to have potential to be verbally aggressive very rude and demanding r/t cognitive impairment. He had impaired cognitive function r/t dementia. He had a mood problem r/t MDD and declines to see psych. Interventions included administering medications as ordered, explain all procedures and orders prior to starting and allow time to adjust to changes, discuss inappropriate behaviors with resident when reasonable, monitor behavior episodes and attempt to determine underlying causes, and document behaviors and potential causes. Staff were instructed to give the resident 5-10 minutes when resistive to care before trying again and when he became agitated to intervene before the agitation escalated and guide him away from the source of distress. Staff were instructed to engage him calmly in conversation and if he became aggressive they were to walk calmly away and approach at a later time.Record review of Resident #3's active orders dated 09/11/25 revealed the following orders with corresponding start dates:05/18/25 Aspirin EC Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for Pain -Moderate11/20/24 Carbidopa-Levodopa Oral Tablet 25-250 MG(Carbidopa-Levodopa) Give 1 tablet by mouth five times a day related to PARKINSON'S DISEASE WITHOUT DYSKINESIA, WITHOUT MENTION OF FLUCTUATIONS09/03/25 clonazePAM Oral Tablet 0.5 MG (Clonazepam) Give 1 tablet by mouth three times a day related to ANXIETY DISORDER, UNSPECIFIED03/15/25 DULoxetine HCl Oral Capsule Delayed Release Sprinkle 30 MG (Duloxetine HCl) Give 1 capsule by mouth in the afternoon for dep03/14/25 DULoxetine HCl Oral Capsule Delayed Release Sprinkle 30 MG (Duloxetine HCl) Give 2 capsule by mouth at bedtime for dep related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED07/30/25 Mirtazapine Oral Tablet 30 MG (Mirtazapine) Give 1 tablet by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED09/10/25 Vistaril Oral Capsule 50 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth every 04 hours as needed for anxiety for 14 DaysRecord review of a referral order dated 09/10/25 revealed Resident #3 was being referred for Psychiatric Medication Management and Psychotherapy and Counseling Services.Record review Resident #3's progress notes from 03/11/25 to 09/12/25 revealed no mention of physical or verbal aggression toward another resident.During an observation and interview on 09/11/25 at 08:23 AM Resident #2 stated a male resident had a saw yesterday and threatened to cut off her feet and then cut on her walker. She gestured to the top, front bar of her walker.During an observation and interview on 09/11/25 at 08:36 AM Resident #2 was seen leaving ADON's office and stated she told ADON about the man threatening to cut off her feet with a saw.During an observation and interview on 09/11/25 at 08:36 AM ADON stated she was just told by Resident #2 about Resident #3 threatening her with a saw on 09/10/25.During an observation and interview on 09/11/25 at 08:41 AM ADM stated Resident #3 had a hand saw on 09/10/25. She stated, He took it out of the maintenance room is the only thing we can figure out. ADM stated CNA A and CNA B were working at the time and took the saw away from Resident #3. When asked if he used the saw to threaten Resident #2 and/or cut on her walker, ADM shook her head and stated, What you are going to find out is [name of Resident #2] doesn't tell the truth.During an interview on 09/11/25 at 08:50 AM CNA A stated regarding Resident #3 on 09/10/25, I mean he did have a saw but as soon as we seen him, we took it from him. He was rolling with the saw down the hall. She stated she did not hear him threaten Resident #2 or see him using the saw on Resident #2's walker. She stated she was trained regularly on recognizing and reporting suspected abuse and neglect. She stated she was to report suspected abuse and neglect to ADM.During an interview on 09/11/25 at 08:51 AM CNA B stated Resident #3 had a saw on 07/10/25 and he was using the saw on Resident #2's walker. She stated, You can look at her walker. There is proof. CNA B stated Resident #3 got the saw from the maintenance office. She stated she reported the incident to ADM and ADON as soon as the saw was taken away from Resident #3 on 09/10/25. She stated she was trained regularly on reporting suspected abuse and neglect and she was to report to ADM.During an interview on 09/11/25 at 09:00 AM Resident #3 was lying in bed in his room. He stated he had a saw yesterday (09/10/25) and he got the saw from the shop (here he gestured with his left hand in the direction of the hallway which housed the maintenance office. Resident #3 was asked if he threatened to cut off a Resident #2's feet with the saw and he answered, Foot. He stated he threatened to cut off her foot. When asked if he used the saw on the female resident's walker, he said he did. During an observation on 09/11/25 at 09:03 AM of Resident #2's top, front walker bar revealed a small, shallow groove approximately 1.5 centimeters in length and 2 millimeters in depth with jagged edges.During an interview on 09/11/25 at 09:07 AM CNA K stated she was trained often on recognizing and reporting suspected abuse and neglect. She stated she was to report to her charge nurse or to ADM.During an interview on 09/11/25 at 09:08 AM HSK stated she was trained regularly on recognizing and reporting abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM.During an interview on 09/11/25 at 09:19 AM RN C stated she was trained regularly on recognizing and reporting abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM.During an interview on 09/11/25 at 01:57 PM LVN D stated she was trained regularly on recognizing and reporting abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM.During an interview on 09/11/25 at 02:23 PM DON stated she was not in the building on 09/10/25 when Resident #3 had a hand saw and it was not reported to her.During an interview on 09/11/25 at 02:35 PM ADON stated on 09/10/25 around 4 or 5 PM Resident #3 had a hand saw. She stated she did not see him with the saw she just heard about him having it. She stated she received a phone call from LVN J on 09/10/25. LVN J told ADON it was reported to her (LVN J) Resident #3 had a hand saw that afternoon.During an interview on 09/11/25 at 02:43 PM ADM stated she was in the building on 09/10/25 when Resident #3 had a hand saw. She stated she did not see him with the hand saw but CNA A and CNA B told her about taking the saw from Resident #3. During an interview on 09/11/25 at 04:23 PM LVN G stated Resident #3 had a hand saw and was cutting on the top, front bar of Resident #2's walker and making fun with everyone who was in the common area that he could saw through the walker. She stated she went to his side and asked him to put the saw down because it was not his. LVN G stated she was trained regularly on recognizing and reporting abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM.During an observation on 09/11/25 at 05:04 PM Resident #3 was wheeling himself into the front door after smoking in the courtyard. He had been in the courtyard with ADON but came back into the facility on his own.During an interview on 09/12/25 at 08:16 AM CNA H stated she was trained regularly on recognizing and reporting abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM.During an interview on 09/12/25 at 08:40 AM ADON stated she was not sure if the facility was going to report the incident of Resident #3 threatening Resident #2 with a hand saw. During an interview on 09/12/25 10:48 AM ADM stated she was not sure why the incident of Resident #3 having a hand saw needed to be reported. She stated she did not think any contact was made between the saw and Resident #2's walker. She stated if she reported the incident on 09/12/25 it would be late.During an interview on 09/12/25 at 10:57 AM CNA B stated she reported the incident of Resident #3 having a saw and using it to saw on Resident #2's walker to ADM and ADON right after it happened on 09/10/25.During an interview on 09/12/25 at 10:58 AM ADON stated she did not tell ADM about Resident #3 having a hand saw after LVN J called and told her (ADON). She stated she did not know how ADM found out about the incident.During an interview on 09/12/25 at 11:01 AM LVN G stated she could not remember if she reported to ADM, DON, or ADON Resident #3 had a saw and used it to saw on Resident #2's walker.During an interview on 09/12/25 at 12:45 PM CNA B stated after she reported to ADM and ADON on 09/10/25 nothing was done to investigate the incident or ensure residents were safe until this surveyor began asking questions about the incident on 09/11/25 at which point staff were in-serviced. She stated a possible negative outcome of not reporting abuse or neglect was, They (residents) are scared, worried, at risk. They don't know what's gonna happen.On 09/12/25 at 01:00 PM ADM and ADON were notified that an Immediate Jeopardy had been identified, IJ templates were provided, and Plan of Removal was requested.During an observation on 09/12/25 at 02:04 PM Resident #3 was observed wheeling himself out the front door of the facility.During an interview on 09/12/25 at 02:54 PM ADON stated a possible negative outcome of not reporting/investigating the incident of Resident #3 threatening Resident #2 according to facility policy was, Somebody could have been hurt. During an interview on 09/12/25 at 02:57 PM DON stated a possible negative outcome of not reporting/investigation the incident of Resident #3 threatening Resident #2 according to facility policy was, It could occur with another resident.The facility's Plan of Removal (as follows) was accepted on 09/12/25 at 08:12 PM.Plan of Removal Tag F 607Problem: There is a need for immediate action due to the break in the facilities policy to ensure residents are free from abuse and neglect. Specifically, the facility staff will need to address corrective action to prevent future incidents of resident to resident abuse from occurring in the facility, especially when residents are exhibiting signs and symptoms of aggressive behavior. All residents who are high risk for elopement are at risk of the alleged defected deficiency.Resident obtained the hand saw due to the maintenance office being locked [sic]. The facility was neglectful in leaving the door unlocked. This has been addressed for the future by installing a self-locking door knob. This will ensure that no one can get into the maintenance office unauthorized again and removes the potential for future neglect or harm.All staff were re-educated on the facility's policies and procedures related to abuse & neglect.Staff directly involved in the incident received targeted retraining focused on compliance, resident rights, and recognition/prevention of neglect and abuse. Interventions:The administrator notified the medical director of Immediate Jeopardy 9/12/25 & anAd HOC completed on 9/12/2025.Physician and family were notified on 9/12/2025.Facility reported the incident to state on 9/12/2025.Copies of the abuse policy are now posted in staff areas for quick reference.Resident was placed on Q 15-minute checks for 72 hours and will re-evaluate for continued of need of 15 minutes checks.The following in-services were provided:All facility staff (all staff/all departments: ADON, licensed nurses, certified nursing assistants, dietary, housekeeping, laundry, activity director, maintenance) have been in-serviced on Reporting Abuse/Neglect Abuse Definitions Behavior interventions Behavior crisis Freedom from abuse Abuse prevention Resident rights Any Resident-to-Resident Near Miss (an incident between two residents that wereverbal and physical in nature but did not cause injury) Any Resident-to-Resident Altercation where physical contact has been made but did notresult in injury will need to be reported to the Administrator. Resident-to-Resident alterationsThe Administrator has been in-serviced on the topic of Abuse, including Abuse Definitions, Abuse Policies and Procedures, Freedom from Abuse, Resident Rights, Behavior Intervention, Behavior Crisis, Abuse Prevention, Injury of Unknown Source, on 2/6/2025 by [NAME] RDO, and [NAME] Regional Nurse Consultant.On 9/12/2025 the Administrator and Director of Nursing were provided education regarding thorough investigations for abuse and neglect, and injury of unknown source by the RDO and Regional Nurse Consultant.On 9/12/2025 the Administrator and Director of Nursing were provided education regarding reporting allegations of abuse and neglect, and injury of unknown source to the state by the RDO and Regional Clinical Nurse Consultant.Resident #3 does not have a history of physical behavior; this was an isolated incident, however on 9/12/2025 the DON added a care plan for aggressive behaviors.On 9/12/2025 that Care plan was updatedDON/designee will conduct random staff interviews weekly x 8 weeks, then monthly x 4 months, asking staff how to identify and report abuse and neglect. Leadership will ensure mandatory annual abuse training is completed by 100% of staff.We identify that all residents residing in the facility have the potential to be affected by this alleged deficient practice.Psychosocial completed on both residents on 9/12/2025. Charge nurse counseled resident to not use the hand on 9/10/2025. Resident verbalizes understanding of the risk of potential harm.Referral obtained for referral for psych evaluation.Order received for anti-anxiety medication which was administered with resident consent.All facility employees are required to report all suspected abuse, injury of unknown source, and any resident-to-resident altercation to the Administrator and/or the DON if either cannot be reached in a timely fashion.Administrator will audit personnel files monthly for evidence of abuse prevention and training.DON/Designee will monitor Daily M-F, and the Weekend RN supervisor on Saturday and Sunday for 60 days the 24-hour reports, incident reports, and behavior monitoring sheets to ensure the facility identifies any type of possible abuse, neglect, or injury of unknown source.The NHA will review the 24-hour report, incident and accident reports daily M-F, and the Weekend RN supervisor on Saturday and Sundays for 60 days to ensure accurate documentation and interventions are put in place to ensure all possible abuse incidents, resident-to-resident altercations are properly identified and reported to ensure the facility properly identifies, investigates, reports, and implements interventions as required.The NHA will report any changes with this Plan of Removal to the QAPI committee as necessary.Inservices [sic] began 9/12/25 and all staff to be inserviced [sic] prior to beginning shift. Monitoring the Plan of Removal (POR) included:On 09/13/25 record review revealed the in-services, Ad HOC meeting (on 09/12/25), physician and family notifications, care plan updates, psychosocial assessments on Residents #2 and #3 (dated 09/12/25 and showing no issues for either resident), order for antianxiety medication for Resident #3 (dated 09/10/25) facility incident report to state (dated 09/12/25), posting of abuse policy, referral for psych services for Resident #3(dated 09/10/25) and starting of Q-15 minute checks on Resident #3 were completed.Interview with ADM, DON, and ADON on 09/13/25 at 11:00 AM revealed all facility staff had received the in-services started on 09/12/25 regarding elopement and accidents/hazards. ADM stated ADON had been calling staff who were not in the building and following the calls by sending an email copy of the in-service. ADM and DON stated they had been trained by their corporate representatives on investigation and reporting of suspected abuse/neglect. Record review of the in-services provided to ADM and DON on 02/06/25 revealed they were trained on the definition of abuse, abuse policies and procedures, freedom from abuse, resident rights, behavior intervention and crisis, abuse prevention, injury of unknown origin, and reporting.Record review of the in-service provided to staff by corporate on 09/12/25 revealed staff were trained on proper reporting and timely report, abuse policies and procedures including abuse definitions, freedom from abuse, resident rights, behavior interventions, behavior crisis, abuse prevention, injury of unknown source, thorough investigations for abuse and neglect and injury of unknown source, reporting of allegations of abuse to state and corporate, and reporting of allegations of abuse, neglect, and injury of unknown source to state. Record review of in-service provided to staff on 09/12/25 by ADON revealed staff were trained on Safe Storage, Random check to ensure maintenance doors are locked, Abuse/Neglect/Exploitation reviewed/posted, Investigating and reporting Incidents/Accidents, Appropriate assessments/interventions, Resident Rights.During an interview on 09/13/25 at 11:14 AM DA stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained yesterday on recognizing if a resident was attempting to elope and intervening as necessary. DA stated she was trained on keeping hazardous items out of reach of residents and in locked compartments. During an interview on 09/13/25 at 11:16 AM LVN D stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on keeping hazardous items locked and out of resident reach and on recognizing residents at risk of elopement.During an interview on 09/13/25 at 11:18 AM CNA I stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on keeping hazardous items locked and out of resident reach and on recognizing residents at risk of elopement. CNA I stated she was trained to keep wipes and cleaning solutions locked in the cabinet or in the shower room and she was trained on her part if a resident was missing from the facility to include searching her unit and counting the residents on her unit.During an interview on 09/13/25 at 11:23 AM CNA B stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on her part if a resident eloped from the facility as well as on keeping hazardous items out of reach of residents. During an interview on 09/13/25 at 11:24 AM RN SUP stated she was trained today (09/13/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on her part if an elopement took place and on keeping hazardous items out of reach of residents. RN SUP stated she has been trained on her responsibilities regarding reviewing incident accident reports and 24-hour report on the weekends.During an interview on 09/13/25 at 11:27 AM [NAME] stated she was trained today (09/13/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on recognizing if a resident was trying to elope and on how to intervene. [NAME] stated she was trained on keeping hazardous items out of reach of residents. During an interview on 09/13/25 at 11:29 AM CNA H stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on keeping hazardous items out of reach of residents and locked in appropriate cabinets or rooms and on her part if a resident attempted or succeeded in eloping.During an interview on 09/13/25 at 11:32 AM CNA F stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on keeping dangerous items locked up and out of reach of residents. She stated she was trained on her part if an elopement occurred.During an interview on 09/13/25 at 11:35 AM RN C stated she was trained yesterday (09/12/25) and today (09/13/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. RN C stated she was trained on her part if a resident attempted or succeeded in eloping and she was trained on keeping hazardous items locked up and out of reach of residents. During an observation on 09/13/25 at 11:40 AM ADM demonstrated the new self-locking doorknob on the maintenance office by unlocking it with a key and closing the door again. It was locked. The new doorknob was smooth on the inside of the door with no locking or unlocking mechanism aside from the keyhole on the outside of the door.Record review on 09/13/25 of Resident #3's revised care plan revealed a note regarding the incident on 09/10/25 with the handsaw. Interventions included Q 15-minute checks as indicated and documenting any signs or symptoms of resident posing a danger to himself or others. Staff were to ensure the maintenance office door was locked at all times.Record review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program and dated April 2021 revealed the following: .The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents; c. consultants; d. volunteers; e. staff from other agencies; f. family members; g. legal representatives; h. friends; i. visitors; and/or j. any other individual. 2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; b. neglect of residents; and/or c. theft, exploitation or misappropriation of resident property. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements. 10. Protect residents from any further harm during investigations.Record review of facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating and dated April 2021 revealed the following: . All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for detem1ining what actions (if any) are needed for the protection of residents. Investigating Allegations 1. All allegations are thoroughly investigated. The administrator initiates investigations. 2. Investigations may be assigned to an individual trained in reviewing, investigating and reporting such allegations. 3. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. a. Any evidence that may be needed for a criminal investigation is sealed, labeled and protected from tampering or destruction. 4. The administrator is responsible for keeping the resident and his/her representative (sponsor) informed of the progress of the investigation. 5. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. 7. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have bad contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members, and visitors; j. interviews other residents to whom the accused employee provides care or services; k. reviews all events leading up to the alleged incident; and I. documents the investigation completely and thoroughly.On 09/13/25 at 12:08 PM ADM, DON, and ADON were informed the IJ was removed as of 12:08 PM. An IJ was identified on 09/12/25. The IJ template was provided to the facility on [DATE] at 01:00 PM. While the IJ was removed, the facility remained out of compliance at a level of no actual harm potential for more than minimal harm not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observations, interviews, and record reviews the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 2 (Resident #1 and Resident #3) of 5 residents reviewed for accidents and hazards.1. The facility failed to ensure Resident #1 did not elope on 08/21/25 in his manual wheelchair 8 days after he had cranioplasty surgery .5 of a mile from the facility on his way to the hospital.2. The facility failed to ensure Resident #3 did not have access to a hand saw from the unlocked maintenance office.These failures could place residents at risk of injury or death.An Immediate Jeopardy (IJ) was identified on 09/12/25 at 01:00 PM. Although the IJ was removed on 09/13/25 at 12:08 PM the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. Plan of Removal of IJ will be included in findings.Findings Included:1. Record review of Resident #1's admission record dated 09/11/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, stroke), aphasia (a disorder that affects the ability to communicate, read, write, and understand language caused by damage or injury to the specific area of the brain responsible for language), hemiplegia and hemiparesis following cerebral infarction (partial paralysis following stroke) affecting right dominant side, muscle wasting and atrophy, muscle weakness, and other lack of coordination.Record review of Resident #1's quarterly MDS completed on 08/08/25 revealed a BIMS score of 12 which indicated moderately impaired cognition. Section GG Functional Abilities revealed he had impairment on one side to both upper and lower extremities and utilized a manual wheelchair. He was noted to require substantial/maximal assistance with toileting, bathing, personal hygiene, and dressing. He was noted to be independent wheeling himself once he was seated in his wheelchair. Section J Health Conditions revealed Resident #1 received scheduled pain medication and PRN pain medications. His pain was noted to be occasional, severe, and rarely interfered with sleep and day-to-day activities.Record review of Resident #1's care plan completed on 08/08/25 revealed he was a wanderer r/t confusion. The goal was, The resident's safety will be maintained through the review date. Interventions included distracting him by offering diversions and identifying if his wandering had a pattern. Resident #1 was noted to have impaired cognitive function r/t CVA. Interventions included asking him yes/no questions to determine his needs and The resident needs supervision with all decision making. He was noted to have a communication problem r/t Aphasia; makes sounds and gestures to communicate. Resident #1 was noted to have poor balance, impaired though process and to be very mobile in wheelchair and require supervision. One of the interventions for this area of the care plan was to ensure he was wearing appropriate footwear with ambulating or mobilizing in his wheelchair. He was noted to need a safe environment with: even floors . Resident #1 slid out of his wheelchair on 03/02/25 and fell on [DATE] during a self- transfer. He was noted to have hemiplegia/hemiparesis r/t CVA. He was noted to have chronic pain. Staff were to evaluate the effectiveness of pain interventions and notify the physician if interventions were unsuccessful or if current complaint was a significant change from his past experience of pain. Resident #1 was able to answer yes/no by nodding or shaking his head and to gesture thumbs up or thumbs down to assist in pain assessment. He was noted to have bladder incontinence.Record review of Resident #1's order summary report dated 09/11/25 revealed the following orders with corresponding order start dates:02/27/25 Gabapentin Oral Capsule (Gabapentin) Give 300 mg by mouth two times a day for pain - Moderate11/17/24 [Brand name of Acetaminophen] Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for PainRecord review of Resident #1's MAR for June 2025 revealed he received Gabapentin as ordered all 30 days of the month. He received 650 mg of acetaminophen on the following dates with corresponding pain levels and the medication was effective: 06/01/25 level 10, 06/04/25 level 9, 06/05/25 level 9, 06/24/25 level 9, 06/25/25 level 3.Record review of Resident #1's MAR for July 2025 revealed his Gabapentin was on hold by the physician from 07/22/25 through 08/01/25. Resident #1 received Gabapentin as ordered from 07/01/25 through the morning dose on 07/22/25. He received 650 mg of acetaminophen on the following dates with corresponding pain levels and the medication was effective: 07/04/25 level 2, 07/05/25 level 7, 07/13/25 level 9, 07/15/25 level 3, 07/16/25 level 3, 07/18/25 level 8, 07/19/25 level 7, 07/19/25 level 3, 07/20/25 level 5, 07/20/25 level 2, 07/21/25 level 3, 07/23/25 level 3, 07/24/25 level 4, 07/26/25 level 3, 07/27/25 level 2, 07/28/25 level 4, 07/29/25 level 3, 07/31/25 level 4, 07/31/25 level 3. Record review of Resident #1's MAR for August 2025 revealed his Gabapentin was on hold by the physician from 08/01/25 through 08/06/25. Resident #1 received Gabapentin as ordered from 08/06/25 evening dose through 08/12/25. He was in the hospital from [DATE] to 08/16/25. He received Gabapentin as ordered from the evening dose on 08/16/25 through 08/20/25. Resident #1 received 650 mg of acetaminophen on the following dates with corresponding pain levels and the medication was effective: 08/02/25 level 3, 08/03/25 level 3, 08/04/25 level 4, 08/04/25 level 4, 08/05/25 level 5, 08/05/25 level 3, 08/06/25 level 3, 08/07/25 level 7, 08/08/25 level 3, 08/09/25 level 7, 08/09/25 level 3, 08/10/25 level 4, 08/10/25 level 3, 08/11/25 level 5, 08/11/25 level 3, 08/12/25 level 3, 08/16/25 level 3, 08/17/25 level 3, 08/18/25 level 5, 08/18/25 level 5, 08/18/25 level 4, 08/19/25 level 6, 08/19/25 level 7, 08/19/25 level 2, 08/19/25 level 6, 08/20/25 level 5, 08/20/25 level 5. On 08/21/25 he received acetaminophen as ordered at 05:51 AM and it was unknown if it was effective due to his elopement.Record review of Resident #1's elopement risk assessments dated 10/12/24, 04/05/25 and 06/06/25 revealed he was a low risk for elopement with no previous attempts at eloping.Record review of Resident #1's progress notes from 03/11/25 to 08/21/25 revealed his hernia was mentioned 4 times.On 05/07/25 at 13:11 (01:11 PM) he complained of pain to his inguinal area due to hernia. Acetaminophen 650 mg was administered and effective.On 07/03/25 at 08:26 AM the urologist's office called to inform facility staff a referral had been sent to a general surgeon for Resident #1's hernia. Office of surgeon will reach out with appointment time and date.On 08/21/25 at 07:47 AM LVN D documented the following: THIS NURSE DISCOVERED RESIDENT LEFT FACILITY THIS MORNING FROM DINING ROOM AREA WHILE WAITING FOR PARAMEDICS TO ARRIVE TO TRANSPORT RESIDENT TO [name of hospital] HOSPITAL DUE TO NCREASED PAIN FROM EXISTING HERNIA TO LEFT AREA ON TESTICLES. SAW RESIDENT AT ABOUT 7 IN THE MORNING WHILE WALKING THROUGH DINING ROOM TO ASSIST ANOTHER RESIDENT WITH A FINGERSTICK. ALERTED ALL STAFF IN THE BUILDING OF MISSING RESIDENT. ALL STAFF PROCEEDED TO LOOK FOR RESIDENT IN THE BUILDING, OUTSIDE ON FOOT, AND A NURSING AIDE GOT IN HER CARTO [sic] GO LOOK FOR HIM, WHILE THIS NURSE INFORMED [name of ADM] THE ADMINISTRATOR, [name of ADON] ADON. NURSING AIDE IN CAR WENT TO [name of hospital] HOSPITAL AND DISCOVERED RESIDENT WAS THERE. [name of ADM] ADMINISTRATOR [name of ADON] ADON, AND [name and relationship of family member] ALLINFORMED [sic] RESIDENT WAS FOUND SAFE AT THE HOSPITAL. [name of FNP] FNP ALSO INFORMED. [name of hospital] INFORMED THIS NURSE RESIDENT IS TO HAVE SURGERY FOR THE HERNIA. PARAMEDICS ARRIVED AT [name of facility] AT 1 PM TO PICK UP THE RESIDENT THEY WER [sic] TOLD THE RESIDENT WAS GONE OUT TO TEH [sic] HOSPITAL.On 08/21/25 at 06:08 AM LVN E documented the following: Was finishing up report with [name of LVN D] LVN, when patient came out of room without clothes on, yelling and gesturing to head and crotch. Pt is aphasic, and keeps pointing to these areas. This SN had given PRN [brand name of acetaminophen] earlier at 0551 (05:51 AM) per pt request, fot [sic] HA, andc/o [sic] of Left hernia pain to existing hernia. Then went back to bed, and wasn't agitated at that time. [name of LVN D] LVN assumed care of patient at this time.Record review of Resident #1's hospital records for his hospital stay 08/21/25 to 08/26/25 revealed the following:On 08/21/25 at 07:22 AM he arrived at the hospital. His means of arrival was noted to be Wheelchair.On 08/21/25 at 07:30 AM HC noted, Chaplain encountered patient while he was in triage. Chaplain remembered this patient from previous visit to have surgery and is aware of communication barriers. Chaplain helped patient communicate with nursing staff as much as possible and remained with patient. Chaplain will continue to follow to provide support.On 08/21/25 at 07:33 AM it was noted, Asked pt if he is having pain and he points to his genital area. Asked pt if he has been able to go to the restroom and pt states 'no.'On 08/21/25 at 07:44 AM it was noted, [Name of facility] employee arrived to ER stating that they were missing a patient. This employee presented badge and was able to describe the patient. This employee provided this patients paperwork from [name of facility] with demographics available. Pt demographics updated in pt chart.On 08/21/25 at 11:04 AM it was noted, Pt was found in [name of city park across the street from the hospital] by a bio-med employee. He was unable to state his name or DOB. Pt is pointing to his testicles and scrotum. He appears to be c/o pain and swelling. Pt has not been able to pass urine. Hx/ROS are limited. General: He (Resident #1) is in acute distress. Appearance: He is ill-appearing. He is not toxic-appearing . Testes: Left: Tenderness and swelling (redness) present . Mental Status: He is alert and oriented to person, place, and time. Left inguinal hernia (part of fatty tissue or intestines protrudes through a weak spot in abdominal wall in left groin area) with urinary bladder down and testicular area discussed with surgery who will take to the OR.On 08/21/25 at 12:48 PM it was noted, The patient came in the emergency room today. He lives in a nursing home and was having increasing groin and scrotal pain as well as difficulty urinating. He was found to have a large left inguinal hernia with most of his bladder coming out through the hernia and into his scrotum on this side. On physical examination, he has some tenderness and fullness in the left side of his groin and scrotum. CT scan is reviewed which shows the left inguinal hernia with a large portion of his bladder extending down into the scrotum. I discussed plans with the patient. The patient is not able to speak very much . He does appear to understand what you're saying very well. S/p Craniotomy, Decompressive Craniectomy in 2024. S/p cranioplasty with replacement of bone flap 8/13/25.On 08/21/25 at 04:02 PM Resident #1's left inguinal hernia surgery was begun.On 08/26/25 Resident #1 was discharged from the hospital. His discharge summary note read, The patient was admitted through the emergency room with a symptomatic left inguinal hernia with bladder in it. He underwent a complex repair of the inguinal hernia. His postoperative course was uneventful. The patient had previously been in a nursing home and the family wanted to move him to a different facility postop therefore he was in the hospital for a few days awaiting placement. He was discharged in good condition .Record review of Resident #1's Documentation Survey Report for August 2025 dated 09/11/25 revealed no indication of urinary retention in the days prior to his elopement on 08/21/25. On 08/18/25 he urinated at 12:43 AM and 01:06 PM. On 08/19/25 he urinated at 07:34 AM, 10:22 AM, and 11:47 PM. On 08/20/25 he urinated at 09:02 AM, 10:18 AM, 09:40 PM and 10:04 PM.Record review of weather on 08/21/25 at 07:00 AM revealed the temperature was approximately 70 degrees Fahrenheit with a 5-mph wind and 81% humidity.Record review of Resident #1's History and Physical dated 04/09/25 revealed the following: . Patient has been discharged from hospice services. The facility reports [Resident #1's family member] is wanting him to go back and see the surgeon that did his brain surgery. Staff reports she is concerned about his skull being sunken in and is wanting to have this fixed. She also wants him to have a hernia repair but her first concern is the skull.During an interview on 09/11/25 at 09:19 AM RN C stated she worked with Resident #1. She stated he had a communication deficit but he would get his point across with yes and no questions and hand gestures. She stated she was working on 08/21/25 when Resident #1 eloped but she was not his nurse that day. She stated there were a lot of safety issues with Resident #1 wheeling himself to the hospital. She stated, A lot of things could happen, he could get hit.During an interview on 09/11/25 at 09:32 AM Resident #1's family member stated on 08/21/25 at 06:15 AM she got a call from LVN D saying Resident #1 wanted to go to the hospital and the facility was going to call an ambulance. She stated she received another call from LVN D on 08/21/25 at 07:41 AM telling her Resident #1 was not in the facility but he had managed to wheel himself to the ER. Resident #1's family member stated another family member called and told her to call HC. She stated HC knew Resident #1 from his stay in the hospital for his cranioplasty surgery the week before. HC told her Resident #1 was found near the park across the street from the hospital struggling with his wheelchair and a hospital staff person left his car there on the side of the street and pushed Resident #1 the rest of the way to the ER. She stated Resident #1 had a huge scar and stitches and staples from his forehead and back around to his left ear due to the cranioplasty he had on 08/13/25. Resident #1's family member stated the scar made the hospital staff member who stopped to help him think he had escaped from the hospital and was lost. She stated when he eloped Resident #1 was not wearing his glasses or his teeth or shoes. She stated he only had on socks. She stated when he woke up from his hernia surgery the first things he asked for were his glasses and his teeth. Resident #1's family member stated, When you talk to him it is like playing charades because he only knows 3 words and he gestures. She stated on 08/26/25 when she picked up Resident #1's belongings from the facility ADM told her the ambulance showed up to pick up Resident #1 seven hours after it had been called. She stated, He should never have been able to leave! His safety (was at risk)!During an interview on 09/11/25 at 11:06 AM CD stated a 911 call came in on 08/21/25 at 06:17 AM from the facility requesting an ambulance for Resident #1 due to hernia pain. She stated the ambulance arrived at the facility on 0821/25 at 01:19 PM. She stated operations had downgraded the call to non-emergent.During an interview on 09/11/25 at 11:16 AM HC stated she was in the ER on the morning of 08/21/25 and heard nurses speaking about an unidentified person who was brought to the ER from the park across the street. She said she walked by and recognized the person was Resident #1. She stated, I went over there, and he saw me and burst into tears. He was sitting in a w/c . and he grabbed my arm and held onto it and cried and cried and cried. She stated she referred to her notes from his stay on 08/13/25 and called his family member. HC said, We played some charades for a while, and he communicated to me that he had left the nursing home. She stated Resident #1 indicated to her that he was in pain. She stated a hospital employee saw Resident #1 across the street from the hospital near the park. She stated the employee left his car and pushed Resident #1 in his wheelchair the rest of the way to the ER. During an interview on 09/11/25 at 12:00 PM ADM and ADON stated Resident #1 had no history of elopement. During an observation on 09/11/25 at 12:04 PM this surveyor drove the route from the facility to where Resident #1 was found by hospital staff. It was .5 of a mile and had sidewalks for 3/4 of the route. Some portions of the sidewalks were not accessible by wheelchair and there was no bike lane. The 1/4 of the route with no sidewalks did have a bike lane. The first .4 of a mile was flat or downhill. Some portions of the downhill route were rather steep. The last .1 of a mile was uphill. From where Resident #1 was found and assisted by hospital staff the route was all uphill to include a steep drive from the street to the hospital ER entrance. During an interview on 09/11/25 at 01:57 PM LVN D stated on 08/21/25 at around 06:00 AM she and LVN E were exchanging report and Resident #1 came out of his room with no clothes on complaining of pain. She stated she and LVN E dressed Resident #1 and told him it might be good to lie down and get off that hernia. She stated he got mad and said, No, no, no. LVN D stated Resident #1 let her know he wanted to go to the hospital, and she called the ambulance and got his paperwork ready while he sat near her. She stated, The ambulance was taking so long, and he got more agitated. LVN D stated she called the ambulance to find out why it was taking so long and was told it would be a while longer as they had emergencies everywhere. She stated she told the dispatch officer that Resident #1 was in pain. LVN D stated Resident #1 was agitated and she could not calm him down. She stated she did finger sticks on a few residents and when she walked back by where Resident #1 had been sitting in his wheelchair, she noticed he was gone. LVN D stated she sent a CNA to the other unit to see if he was there and when he was not there, she let all staff know he was missing and called ADON and ADM to let them know as well. She stated all staff but 1 CNA on each unit began to search the building and the grounds for Resident #1 and CNA F got in her personal car and drove toward the hospital looking for him. LVN D stated CNA F found Resident #1 at the hospital. LVN D stated Resident #1 had just returned to the facility after surgery for something on his head. She stated, He was going to take care of the hernia first but then he decided to take care of his cranial area first. LVN D stated, regarding Resident #1's elopement, He could have got hurt. Anything could have happened to him.During an interview on 09/11/25 at 02:23 PM DON stated Resident #1 had his hernia on admission. She stated his family decided to put him on hospice in January and the hernia was discussed with hospice and they (hospice) said he could not have any intervention while on hospice. DON stated Resident #1 did not have a history of elopement. She stated regarding Resident #1's elopement on 08/21/25, He coulda got run over for one thing. So many things could have happened between here (facility) and there (hospital). DON stated the facility currently had 6-8 residents who were elopement risks.During an interview on 09/11/25 at 02:35 PM ADON stated if Resident #1 had fallen out of his wheelchair during his elopement on 08/21/25 he could have broke something, hit his head, got hit. She stated the facility currently had 8 residents who were elopement risks. ADON stated LVN D called her on 08/21/25 at 07:20 AM to let her know Resident #1 was missing. She stated she was driving to work when CNA F found Resident #1 at the hospital.During an interview on 09/11/25 at 02:43 PM ADM stated Resident #1 did not have a history of elopement. She stated Resident #1 could have been injured during his elopement if he lost his balance and fell out of his wheelchair.During an interview on 09/11/25 at 03:38 PM LVN E stated Resident #1 was real upset when he came out (of his room) during report on 08/21/25. She stated she had not seen him act that agitated during the time she was working with him. LVN E stated Resident #1 did not complain of hernia pain the night of 08/20/25 or overnight into 08/21/25. She stated he did ask for acetaminophen for his joints at bedtime on 08/20/25. She stated he asked for acetaminophen for his joints at bedtime regularly by pointing to his knees arms and she would ask if he was in pain, and he would nod his head. She stated he was not agitated or angry seeming as he was on the morning of 08/21/25.During an interview on 09/11/25 at 04:01 PM CNA F stated she arrived to work on 08/21/25 around 07:30 AM. She stated she saw two CNAs searching around the building for Resident #1. She stated after she clocked in, she got back in her car and drove to the hospital and told them she was looking for a resident. She described Resident #1 to hospital staff, and they took her to him. CNA F said when she saw Resident #1, she asked him why he did not wait for the ambulance, and he shrugged his shoulders at her with his elbows bent and palms facing up and then he touched his left side. She stated Resident #1 seemed normal when she saw him in the hospital. CNA F stated he could have been hurt wheeling himself to the hospital because it is a busy street.During an interview on 09/11/25 at 04:23 PM LVN G stated regarding Resident #1's elopement, He could have got hurt being alone.During an interview on 09/12/25 at 08:16 PM CNA H stated Resident #1 came out of his room on 08/21/25 during morning report complaining of pain and gesturing to his left side. She stated she did not notice any change in his urine output in the days prior to his elopement.During an interview on 09/12/25 at 04:29 PM MD stated an inguinal hernia could go from being fine to becoming a medical emergency and pretty painful pretty quick. He stated regarding Resident #1's elopement, He had mobility issues, he could have fallen out of the chair, hit something, I mean, there was danger.2. Record review of Resident #3's admission record revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Parkinson's disease (chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement) without dyskinesia (abnormality or impairment of voluntary movement), unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), muscle wasting and atrophy, muscle weakness, and other lack of coordination.Record review of Resident #3's quarterly MDS completed 09/05/25 revealed a BIMS score of 12 which indicated moderately impaired cognition. Section E Behavior revealed Resident #3 had no behaviors. Section GG Functional Abilities revealed he was independent across all ADLs. Section M Medications revealed he was receiving antidepressant, antiplatelet, and anticonvulsant medication.Record review of Resident #3's care plan completed on 09/08/25 revealed he was resistive to care r/t impaired cognition and he had potential to be physically aggressive throwing objects r/t behaviors. Resident #3 was noted to have potential to be verbally aggressive very rude and demanding r/t cognitive impairment. He had impaired cognitive function r/t dementia. He had a mood problem r/t MDD and declines to see psych. Interventions included administering medications as ordered, explain all procedures and orders prior to starting and allow time to adjust to changes, discuss inappropriate behaviors with resident when reasonable, monitor behavior episodes and attempt to determine underlying causes, and document behaviors and potential causes. Staff were instructed to give the resident 5-10 minutes when resistive to care before trying again and when he became agitated to intervene before the agitation escalated and guide him away from the source of distress. Staff were instructed to engage him calmly in conversation and if he became aggressive they were to walk calmly away and approach at a later time.Record review of a referral order dated 09/10/25 revealed Resident #3 was being referred for Psychiatric Medication Management and Psychotherapy and Counseling Services.Record review Resident #3's progress notes from 03/11/25 to 09/12/25 revealed no mention of physical or verbal aggression toward another resident.During an interview on 09/11/25 at 08:23 AM a Resident #2 stated a male resident had a saw yesterday and threatened to cut off her feet.During an interview on 09/11/25 at 08:36 AM ADON stated she was just told by Resident #2 about Resident #3 having a saw yesterday.During an interview on 09/11/25 at 08:41 AM ADM stated Resident #3 had a hand saw on 09/10/25. She stated, He took it out of the maintenance room is the only thing we can figure out. ADM stated CNA A and CNA B were working at the time and took the saw away from Resident #3. During an interview on 09/11/25 at 08:50 AM CNA A stated regarding Resident #3 on 09/10/25, I mean he did have a saw but as soon as we seen him, we took it from him. He was rolling with the saw down the hall.During an interview on 09/11/25 at 08:51 AM CNA B stated Resident #3 had a saw on 09/10/25 and he was using the saw on a female resident's walker. She stated, You can look at her walker. There is proof. CNA B stated Resident #3 got the saw from the maintenance office. During an interview on 09/11/25 at 09:00 AM Resident #3 was lying in bed in his room. He stated he had a saw yesterday (09/10/25) and he got the saw from the shop (here he gestured with his left hand in the direction of the hallway which housed the maintenance office. Resident #3 was asked if he threatened to cut off a female resident's feet with the saw and he answered, Foot. He stated he threatened to cut off her foot. When asked if he used the saw on the female resident's walker, he said he did. During an observation on 09/11/25 at 09:03 AM of Resident #2's top, front walker bar revealed a small, shallow groove approximately 1.5 centimeters in length and 2 millimeters in depth with jagged edges.During an observation and interview on 09/11/25 at 09:06 AM this surveyor opened the door into the maintenance office. As the door opened the first thing visible from waist height to the floor was the side of a desk upon which 4 -6 different types of hand saws were hanging. MA was in the maintenance office and stated any time he leaves the office he locks the door behind him. He stated he was working on 09/10/25 but he was not in the office much that day because he was painting all day. He stated MS was working on 09/10/25.During an interview on 09/11/25 at 02:23 PM DON stated she was not in the building on 09/10/25 when Resident #3 had a hand saw. She stated a possible negative outcome of him having a hand saw was definite injury.During an interview on 09/11/25 at 02:35 PM ADON stated on 09/10/25 around 4 or 5 PM Resident #3 had a hand saw. She stated she did not see him with the saw she just heard about him having it. She stated she received a phone call from LVN J on 09/10/25. LVN J told ADON it was reported to her (LVN J) Resident #3 had a hand saw that afternoon.During an interview on 09/11/25 at 02:43 PM ADM stated she was in the building on 09/10/25 when Resident #3 had a hand saw. She stated she did not see him with the hand saw but CNA A and CNA B told her about taking the saw from Resident #3. She stated a possible negative outcome of a resident having access to a hand saw was, Someone could get cut. During an interview on 09/11/25 at 02:53 PM MS stated he heard about Resident #3 having a hand saw. He stated he did not know how Resident #3 got the hand saw because the maintenance office was locked. MS stated, I always lock the door behind me when I'm going out. If it happens to be I made a mistake-I have so much going on and I am always in a hurry-it is a possibility. But there is no excuse for that, and it will not happen again. MS stated a possible negative outcome of a resident having access to a hand saw was, Somebody gets chopped up. He could hurt someone else or hurt himself.During an interview on 09/11/25 at 04:23 PM LVN G stated Resident #3 was agitated on 09/10/25 and was telling her his doctor had increased his Parkinson's medication. She stated he was upset with her when she told him she could not increase his medication without an order and more upset when she called his doctor's office, and they said it was not to be increased. She stated during this time she left Resident #3 at the nurses' station in his motorized wheelchair and she went to help another resident. LVN G stated when she came back to the nurses' station, she saw him with a hand saw cutting on the top, front bar of a female resident's walker and making fun with everyone who was in the common area that he could saw through the walker. She stated she went to his side and asked him to put the saw down because it was not his. LVN G stated he put the saw on the ground when she asked him to put it down. She stated he was still agitated so she called the doctor for an order for something to calm him down and he was given Vistaril which seemed to help calm him down. LVN G stated, Someone could have been cut due to Resident #3 having access to the hand saw.During an observation on 09/11/25 at 05:04 PM Resident #3 was wheeling himself into the front door after smoking in the courtyard. During an interview on 09/12/25 at 12:42 PM RN C stated she was told on 09/12/25 to keep a closer eye on Resident #3.On 09/12/25 at 01:00 PM ADM and ADON were notified that an Immediate Jeopardy had been identified, IJ templates were provided, and Plan of Removal was requested.The facility's Plan of Removal (as follows) was accepted on 09/12/25 at 08:12 PM.Plan of RemovalProblem: There is a need for immediate action due to the break in the facility's risk management process regarding abuse, neglect, and elopement. Specifically, the facility staff will need to address corrective action to prevent future incidents of elopement from occurring in the facility, especially when residents are exhibiting signs and symptoms of elopement. All residents who are high risk for elopement are at risk of the alleged defected deficiency.Interventions: The administrator notified the medical director of Immediate Jeopardy 9/12/25 & Ad HOC completed on 8/22/2025. The following in-services were provided:o On 8/21/25 DON/ADON provided education to staff on Dementia Care: Mental Decline, elopement policy & exit seeking protocol, and wandering/elopement education prior to their next working shift.o On 8/21/25 DON/ADON provided education to charge nurses on wandering/elopement, dementia care: Mental Decline, elopement policy and exit seeking protocol prior to their next working shift.o All staff will be educated by DON/ADON prior to working their next shift with a completion date of 8/21/25. All NEW staff will be educated prior to working their first shift.o On 8/22/25 Admin and DON/ADON provided education to staff on how to identify residents at risk/high risk. DON/ADON completed audit on 8/21/25 to ensure Elopement Assessments have been completed according to protocol. Charge Nurses will complete an Elopement Risk Assessment quarterly, upon admit, and for exit seeking behaviors. The assessment will provide a score to indicate if they are at risk or high risk for elopement. ADMIN/DON will be responsible for ensuring a resident has 1:1 supervision when required and will monitor that it is being followed. For residents who score at risk/high risk for elopement on the elopement assessment, a shoe emblem will be placed above the name pla

Based on observation, interview, and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #2 and Resident #3) of 5 residents reviewed for reporting of abuse/neglect allegations.The facility failed to report an incident from 09/10/25 when Resident #3 obtained a hand saw from an unlocked maintenance closet and used it to threaten Resident #2 and to saw a groove into the top, front bar of Resident #2's walker.This failure could place residents at risk of continued abuse/neglect.Findings Included:1. Record review of Resident #2's admission record dated 09/11/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) with late onset, intermittent explosive disorder (repeated sudden outbursts of anger), psychotic disorder with delusions (severe mental illness including distorted beliefs) due to known physiological condition, and major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities).Record review of Resident #2's admission MDS completed on 06/19/25 revealed a BIMS score of 10 which indicated moderately impaired cognition. Section GG Functional Abilities revealed Resident #2 used a walker. She was noted to require partial/moderate assistance to supervision/touching assistance across all ADLs. Record review of Resident #2's care plan initiated on 06/20/25 revealed she had the potential to be verbally aggressive and yell at other residents and staff related to dementia. Resident #2 was noted to receive antianxiety medication and antipsychotic medication.Record review of Resident #2's active orders revealed the following orders with corresponding start dates:07/30/25 risperiDONE Oral Tablet 0.25 MG (Risperidone) Give1 tablet by mouth at bedtime related to PSYCHOTICDISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION06/11/25 traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime for Headache related to MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES09/11/25 Vistaril Oral Capsule 50 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth every 04 hours as needed for anxiety for 14 Days2. Record review of Resident #3's admission record revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Parkinson's disease (chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement) without dyskinesia (abnormality or impairment of voluntary movement), unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), muscle wasting and atrophy (shrinkage or wasting away of tissue), muscle weakness, and other lack of coordination.Record review of Resident #3's quarterly MDS completed 09/05/25 revealed a BIMS score of 12 which indicated moderately impaired cognition. Section E Behavior revealed Resident #3 had no behaviors. Section GG Functional Abilities revealed he was independent across all ADLs. Section M Medications revealed he was receiving antidepressant, antiplatelet, and anticonvulsant medication.Record review of Resident #3's care plan completed on 09/08/25 revealed he was resistive to care r/t impaired cognition and he had potential to be physically aggressive throwing objects r/t behaviors. Resident #3 was noted to have potential to be verbally aggressive very rude and demanding r/t cognitive impairment. He had impaired cognitive function r/t dementia. He had a mood problem r/t MDD and declines to see psych. Interventions included administering medications as ordered, explain all procedures and orders prior to starting and allow time to adjust to changes, discuss inappropriate behaviors with resident when reasonable, monitor behavior episodes and attempt to determine underlying causes, and document behaviors and potential causes. Staff were instructed to give the resident 5-10 minutes when resistive to care before trying again and when he became agitated to intervene before the agitation escalated and guide him away from the source of distress. Staff were instructed to engage him calmly in conversation and if he became aggressive they were to walk calmly away and approach at a later time.Record review of Resident #3's active orders dated 09/11/25 revealed the following orders with corresponding start dates:05/18/25 Aspirin EC Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for Pain -Moderate11/20/24 Carbidopa-Levodopa Oral Tablet 25-250 MG(Carbidopa-Levodopa) Give 1 tablet by mouth five times a day related to PARKINSON'S DISEASE WITHOUT DYSKINESIA, WITHOUT MENTION OF FLUCTUATIONS09/03/25 clonazePAM Oral Tablet 0.5 MG (Clonazepam) Give 1 tablet by mouth three times a day related to ANXIETY DISORDER, UNSPECIFIED03/15/25 DULoxetine HCl Oral Capsule Delayed Release Sprinkle 30 MG (Duloxetine HCl) Give 1 capsule by mouth in the afternoon for dep03/14/25 DULoxetine HCl Oral Capsule Delayed Release Sprinkle 30 MG (Duloxetine HCl) Give 2 capsule by mouth at bedtime for dep related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED07/30/25 Mirtazapine Oral Tablet 30 MG (Mirtazapine) Give 1 tablet by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED09/10/25 Vistaril Oral Capsule 50 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth every 04 hours as needed for anxiety for 14 DaysRecord review of a referral order dated 09/10/25 revealed Resident #3 was being referred for Psychiatric Medication Management and Psychotherapy and Counseling Services.Record review Resident #3's progress notes from 03/11/25 to 09/12/25 revealed no mention of physical or verbal aggression toward another resident.During an observation and interview on 09/11/25 at 08:23 AM Resident #2 stated a male resident had a saw yesterday and threatened to cut off her feet and then cut on her walker. She gestured to the top, front bar of her walker.During an interview on 09/11/25 at 08:36 AM ADON stated she was just told by Resident #2 about Resident #3 threatening her with a saw on 09/10/25.During an observation and interview on 09/11/25 at 08:41 AM ADM stated Resident #3 had a hand saw on 09/10/25. She stated, He took it out of the maintenance room is the only thing we can figure out. ADM stated CNA A and CNA B were working at the time and took the saw away from Resident #3. When asked if he used the saw to threaten Resident #2 and/or cut on her walker, ADM shook her head and stated, What you are going to find out is [name of Resident #2] doesn't tell the truth.During an interview on 09/11/25 at 08:50 AM CNA A stated regarding Resident #3 on 09/10/25, I mean he did have a saw but as soon as we seen him, we took it from him. He was rolling with the saw down the hall. She stated she did not hear him threaten Resident #2 or see him using the saw on Resident #2's walker.During an interview on 09/11/25 at 08:51 AM CNA B stated Resident #3 had a saw on 07/10/25 and he was using the saw on Resident #2's walker. She stated, You can look at her walker. There is proof. CNA B stated Resident #3 got the saw from the maintenance office. She stated she reported the incident to ADM and ADON as soon as the saw was taken away from Resident #3.During an interview on 09/11/25 at 09:00 AM Resident #3 was lying in bed in his room. He stated he had a saw yesterday (09/10/25) and he got the saw from the shop (here he gestured with his left hand in the direction of the hallway which housed the maintenance office. Resident #3 was asked if he threatened to cut off a Resident #2's feet with the saw and he answered, Foot. He stated he threatened to cut off her foot. When asked if he used the saw on the female resident's walker, he said he did. During an observation on 09/11/25 at 09:03 AM of Resident #2's top, front walker bar revealed a small, shallow groove approximately 1.5 centimeters in length and 2 millimeters in depth with jagged edges.During an interview on 09/11/25 at 02:23 PM DON stated she was not in the building on 09/10/25 when Resident #3 had a hand saw and it was not reported to her.During an interview on 09/11/25 at 02:35 PM ADON stated on 09/10/25 around 4 or 5 PM Resident #3 had a hand saw. She stated she did not see him with the saw she just heard about him having it. She stated she received a phone call from LVN J on 09/10/25. LVN J told ADON it was reported to her (LVN J) Resident #3 had a hand saw that afternoon.During an interview on 09/11/25 at 02:43 PM ADM stated she was in the building on 09/10/25 when Resident #3 had a hand saw. She stated she did not see him with the hand saw but CNA A and CNA B told her about taking the saw from Resident #3. During an interview on 09/11/25 at 04:23 PM LVN G stated Resident #3 had a hand saw and was cutting on the top, front bar of Resident #2's walker and making fun with everyone who was in the common area that he could saw through the walker. She stated she went to his side and asked him to put the saw down because it was not his. During an interview on 09/12/25 at 08:40 AM ADON stated she was not sure if the facility was going to report the incident of Resident #3 threatening Resident #2 with a hand saw. During an interview on 09/12/25 10:48 AM ADM stated she was not sure why the incident of Resident #3 having a hand saw needed to be reported. She stated she did not think any contact was made between the saw and Resident #2's walker. She stated if she reported the incident on 09/12/25 it would be late.During an interview on 09/12/25 at 10:57 AM CNA B stated she reported the incident of Resident #3 having a saw and using it to saw on Resident #2's walker to ADM and ADON right after it happened on 09/10/25.During an interview on 09/12/25 at 10:58 AM ADON stated she did not tell ADM about Resident #3 having a hand saw after LVN J called and told her (ADON). She stated she did not know how ADM found out about the incident.During an interview on 09/12/25 at 11:01 AM LVN G stated she could not remember if she reported to ADM, DON, or ADON Resident #3 had a saw and used it to saw on Resident #2's walker.During an interview on 09/12/25 at 12:45 PM CNA B stated after she reported to ADM and ADON on 09/10/25 nothing was done to investigate the incident or ensure residents were safe until this surveyor began asking questions about the incident on 09/11/25 at which point staff were in-serviced. She stated a possible negative outcome of not reporting abuse or neglect was, They (residents) are scared, worried, at risk. They don't know what's gonna happen.During an interview on 09/12/25 at 02:54 PM ADON stated a possible negative outcome of not reporting the incident of Resident #3 threatening Resident #2 was, Somebody could have been hurt. During an interview on 09/12/25 at 02:57 PM DON stated a possible negative outcome of not reporting the incident of Resident #3 threatening Resident #2 was, It could occur with another resident.Record review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program and dated April 2021 revealed the following: . 9. Investigate and report any allegations within timeframes required by federal requirements.Record review of facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating and dated April 2021 revealed the following: . All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on observations, interviews, and record reviews the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations are thoroughly investigated for 2 (Resident #2 and Resident #3) of 5 residents reviewed for allegation investigation.The facility failed to investigate an incident from 09/10/25 when Resident #3 threatened Resident #2 with a hand saw and then cut a groove in the center of the top, front bar of Resident #2's walker.This failure could place residents at risk of continued abuse or neglect.Findings Included:1. Record review of Resident #2's admission record dated 09/11/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) with late onset, intermittent explosive disorder (repeated sudden outbursts of anger), psychotic disorder with delusions (severe mental illness including distorted beliefs) due to known physiological condition, and major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities).Record review of Resident #2's admission MDS completed on 06/19/25 revealed a BIMS score of 10 which indicated moderately impaired cognition. Section GG Functional Abilities revealed Resident #2 used a walker. She was noted to require partial/moderate assistance to supervision/touching assistance across all ADLs. Record review of Resident #2's care plan initiated on 06/20/25 revealed she had the potential to be verbally aggressive and yell at other residents and staff related to dementia. Resident #2 was noted to receive antianxiety medication and antipsychotic medication.2. Record review of Resident #3's admission record revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Parkinson's disease (chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement) without dyskinesia (abnormality or impairment of voluntary movement), unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), muscle wasting and atrophy (shrinkage and wasting away of tissue), muscle weakness, and other lack of coordination.Record review of Resident #3's quarterly MDS completed 09/05/25 revealed a BIMS score of 12 which indicated moderately impaired cognition. Section E Behavior revealed Resident #3 had no behaviors. Section GG Functional Abilities revealed he was independent across all ADLs. Section M Medications revealed he was receiving antidepressant, antiplatelet, and anticonvulsant medication.Record review of Resident #3's care plan completed on 09/08/25 revealed he was resistive to care r/t impaired cognition and he had potential to be physically aggressive throwing objects r/t behaviors. Resident #3 was noted to have potential to be verbally aggressive very rude and demanding r/t cognitive impairment. He had impaired cognitive function r/t dementia. He had a mood problem r/t MDD and declines to see psych.Record review Resident #3's progress notes from 03/11/25 to 09/12/25 revealed no mention of physical or verbal aggression toward another resident.During an observation and interview on 09/11/25 at 08:23 AM Resident #2 stated a male resident had a saw yesterday and threatened to cut off her feet and then cut on her walker. She gestured to the top, front bar of her walker.During an interview on 09/11/25 at 08:36 AM ADON stated she was just told by Resident#2 about Resident #3 threatening her with a saw on 09/10/25.During an observation and interview on 09/11/25 at 08:41 AM ADM stated Resident #3 had a hand saw on 09/10/25. She stated, He took it out of the maintenance room is the only thing we can figure out. ADM stated CNA A and CNA B were working at the time and took the saw away from Resident #3. When asked if he used the saw to threaten Resident #2 and/or cut on her walker, ADM shook her head and stated, What you are going to find out is [name of Resident #2] doesn't tell the truth.During an interview on 09/11/25 at 08:50 AM CNA A stated regarding Resident #3 on 09/10/25, I mean he did have a saw but as soon as we seen him, we took it from him. He was rolling with the saw down the hall. She stated she did not hear him threaten Resident #2 or see him using the saw on Resident #2's walker.During an interview on 09/11/25 at 08:51 AM CNA B stated Resident #3 had a saw on 07/10/25 and he was using the saw on Resident #2's walker. She stated, You can look at her walker. There is proof. CNA B stated Resident #3 got the saw from the maintenance office. She stated she reported the incident to ADM and ADON as soon as the saw was taken away from Resident #3.During an interview on 09/11/25 at 09:00 AM Resident #3 was lying in bed in his room. He stated he had a saw yesterday (09/10/25) and he got the saw from the shop (here he gestured with his left hand in the direction of the hallway which housed the maintenance office. Resident #3 was asked if he threatened to cut off a Resident #2's feet with the saw and he answered, Foot. He stated he threatened to cut off her foot. When asked if he used the saw on the female resident's walker, he said he did. During an observation on 09/11/25 at 09:03 AM of Resident #2's top, front walker bar revealed a small, shallow groove approximately 1.5 centimeters in length and 2 millimeters in depth with jagged edges.During an interview on 09/11/25 at 02:23 PM DON stated she was not in the building on 09/10/25 when Resident #3 had a hand saw and it was not reported to her.During an interview on 09/11/25 at 02:35 PM ADON stated on 09/10/25 around 4 or 5 PM Resident #3 had a hand saw. She stated she did not see him with the saw she just heard about him having it. She stated she received a phone call from LVN J on 09/10/25. LVN J told ADON it was reported to her (LVN J) Resident #3 had a hand saw that afternoon.During an interview on 09/11/25 at 02:43 PM ADM stated she was in the building on 09/10/25 when Resident #3 had a hand saw. She stated she did not see him with the hand saw but CNA A and CNA B told her about taking the saw from Resident #3. During an interview on 09/11/25 at 04:23 PM LVN G stated Resident #3 had a hand saw and was cutting on the top, front bar of Resident #2's walker and making fun with everyone who was in the common area that he could saw through the walker. She stated she went to his side and asked him to put the saw down because it was not his. During an interview on 09/12/25 at 08:40 AM ADON stated she was not sure if the facility was going to report the incident of Resident #3 threatening Resident #2 with a hand saw. During an interview on 09/12/25 10:48 AM ADM stated she was not sure why the incident of Resident #3 having a hand saw needed to be reported. She stated she did not think any contact was made between the saw and Resident #2's walker. She stated if she reported the incident on 09/12/25 it would be late.During an interview on 09/12/25 at 10:57 AM CNA B stated she reported the incident of Resident #3 having a saw and using it to saw on Resident #2's walker to ADM and ADON right after it happened on 09/10/25.During an interview on 09/12/25 at 10:58 AM ADON stated she did not tell ADM about Resident #3 having a hand saw after LVN J called and told her (ADON). She stated she did not know how ADM found out about the incident.During an interview on 09/12/25 at 11:01 AM LVN G stated she could not remember if she reported to ADM, DON, or ADON Resident #3 had a saw and used it to saw on Resident #2's walker.During an interview on 09/12/25 at 12:45 PM CNA B stated after she reported to ADM and ADON on 09/10/25 nothing was done to investigate the incident or ensure residents were safe until this surveyor began asking questions about the incident on 09/11/25 at which point staff were in-serviced. She stated a possible negative outcome of not investigating abuse or neglect was, They (residents) are scared, worried, at risk. They don't know what's gonna happen.During an interview on 09/12/25 at 02:54 PM ADON stated a possible negative outcome of not investigating the incident of Resident #3 threatening Resident #2 was, Somebody could have been hurt. During an interview on 09/12/25 at 02:57 PM DON stated a possible negative outcome of not investigating the incident of Resident #3 threatening Resident #2 was, It could occur with another resident.Record review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program and dated April 2021 revealed the following: . The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: . 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements. 10. Protect residents from any further harm during investigations.Record review of facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating and dated April 2021 revealed the following: . 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. Investigating Allegations 1. All allegations are thoroughly investigated. The administrator initiates investigations. 7. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have bad contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members, and visitors; j. interviews other residents to whom the accused employee provides care or services; k. reviews all events leading up to the alleged incident; and I. documents the investigation completely and thoroughly.

Based on observation, interview, and record review the facility failed, in accordance with State and Federal laws, to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 (Resident #40) of 15 residents, 1 (hall 200 medication cart) of 4 medication carts, and 1 (east wing treatment cart) of 2 treatment carts reviewed for medication storage. 1. The facility failed to ensure Resident #40 did not have access to nasal decongestant spray. 2. The facility failed to ensure LVN D locked the hall 200 medication cart when it was unattended. 3. The facility failed to ensure LVN E locked the east wing treatment cart when it was unattended. These failures could place residents at risk of injury due to ingesting non-prescribed medications and/or ingesting prescribed medications at incorrect doses or times. Findings Included: 1. Record review of Resident #40's admission record dated 06/10/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included age-related cognitive decline. Record review of Resident #40's annual MDS completed on 05/15/25 revealed Resident #40 had a BIMS score of 12 which indicated moderately impaired cognition. Resident #40 was coded as receiving anticoagulant medication while a resident. Record review of Resident #40's care plan completed on 05/15/25 revealed he had impaired cognitive function related to impaired memory. The care plan noted Resident #40 was on anticoagulant therapy, but did not mention nose bleeds or self-administration of medication. Record review of Resident #40's active orders dated 06/10/25 revealed no order to self-administer medication. The following orders were revealed: Order start date of 05/28/24 for Afrin Original Nasal Solution (Oxymetazoline HCI) 2 unit in both nostrils as needed for Uncontrolled nose bleed [sic]. Order start date of 08/21/24 for Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day . Record review of Resident #40's MAR for the last 6 months (from 01/10/25 to 06/10/25) revealed he received Afrin Original Nasal Solution (Oxymetazoline HCI) 2 unit in both nostrils as needed for Uncontrolled nose bleed [sic] two times. Once on 02/11/25 and once on 02/15/25. During an observation on 06/09/25 at 07:07 AM Resident #40 was lying in his bed with eyes closed. A small nasal spray bottle was on the nightstand beside his bed. During an interview on 06/09/25 at 09:08 AM Resident #40 was on his back in bed with the HOB raised to seated position watching TV. He stated he was hospitalized twice since his admission to the facility. He stated one of the times he was hospitalized was for a bloody nose that wouldn't stop. He stated he was on anticoagulant medication which contributed to the severity of the nosebleed. Resident #40 stated the nosebleed was stopped by spraying Afrin up both nostrils. He then turned and grabbed the small nasal spray bottle from his nightstand and held it up. Resident #40 stated he kept the bottle near just in case he had a nosebleed because that is what the doctor told me to do. During an interview on 06/11/25 at 08:40 AM LVN A stated only one resident in the facility had one medication (a chewable pill) he was allowed to self-administer. She stated a possible negative outcome of residents having medications in their rooms was other residents could take the medication and that would cause harm to them. She stated nurses were trained on administering medications. She stated the pharmacist came monthly to the facility and would train nurses if anything was noted to be [NAME]. During an interview on 06/11/25 at 09:20 AM ADM stated residents were not allowed to have medications in their rooms. She stated, We give them a list of what is not allowed in their rooms at admission. Medication is one of those things. If we notice meds in their rooms, we talk to them about it and take the meds up. ADM stated family members had been known to bring medications to residents. She stated having medications in their rooms could lead to residents being double dosed and it make them ill. During an interview on 06/11/25 at 09:45 AM ADON stated residents could take too much or not remember the dosage if they had medications in their rooms. During an observation on 06/11/25 at 10:20 AM a bottle labelled Major Brand Nasal Decongestant (Oxymetazoline HCI .05%) was sitting on the Resident #40's nightstand. During an interview on 06/11/25 at 10:32 AM DON stated residents were not allowed to have medications in their rooms because the doctor needs to know everything they are taking, including over the counter medication, because it might interact with other medications they are taking. 2. During an observation on 06/09/25 at 06:53 AM LVN D left the hall 200 medication cart unlocked and unobserved while she went into a resident room. During an interview on 06/09/25 at 12:08 PM LVN D stated residents could be negatively impacted by a medication cart left unlocked in that someone can get into the medication cart that is not supposed to, like one of our residents that wander. 3. During an observation on 06/09/25 at 07:03 AM LVN E left the east wing treatment cart unlocked while he performed a glucose check. During an observation on 06/09/25 at 07:07 AM LVN E left the east wing treatment cart unlocked while he interviewed a resident. During an observation on 06/09/25 at 07:16 AM LVN E left the east wing treatment cart unlocked while he administered an inhaler to a resident. During an interview on 06/09/25 at 12:13 PM LVN E stated, There really isn't one (a negative impact to residents for a treatment cart left unlocked). He stated, But I guess someone could get into it. During an interview on 06/11/25 at 08:33 AM ADON stated leaving medication and treatment carts unlocked and unsupervised could lead to a resident getting into the cart and taking medication which could lead to an adverse reaction. During an interview on 06/11/25 at 08:48 AM DON stated a negative outcome of leaving medication and treatment carts unlocked and unsupervised was anyone could get into the cart, we do have residents that wander and pick things up. Record review of facility policy titled Storage of Medications and dated November 2020 revealed the following: . The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drug and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. 3. Nursing staff is responsible for maintaining medication storage . areas in a . safe . manner. 6. Compartments (including, but not limited to, drawer, cabinets rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. Record review of facility policy titled Administering Medications and dated April 2019 revealed the following: . 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Record review of page 35 of the facility's admission packet revealed the following: . AUTHORIZATION OF SELF ADMINISTRATION OF DRUGS Each resident has a right to self-administer drugs if the interdisciplinary team . has determined for each resident that the practice is safe. Record review of an unnumbered, undated page of the facility's admission packet revealed the following: . ITEMS NOT ALLOWED IN RESIDENT ROOMS The following items are not allowed in resident's rooms due to health and safety hazards MEDICATIONS: . No eye, ear, or nasal preparation . No prescription medications of any kind except emergency medication with a [sic] expressed Dr's order that may be kept at bedside .

Based on observations, interviews, 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 kitchen sanitation. The facility failed to ensure foods were properly stored, labeled, and dated. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings Include: Observation of the walk-in refrigerator on 06/09/2025 at 5:55 AM revealed the following: 1. 2 bags of yellow colored cream, the packaging was not labeled or dated. 2. 10 lbs. of ground beef on a flat pan. The pan was labeled: beef-use by 06/07/2025 3. 2 turkeys on a flat pan. The pan was labeled: turkey- use by 06/07/2025 4. 25 small glasses of milk covered-no label or date 5. 26 small glasses of orange juice covered-no label or date 6. 1 container of open cranberry cocktail juice 1/2 full- no open date Observation of walk-in freezer on 06/09/2025 at 6:15 AM revealed the following: 7. 1 box of biscuit type cookies approximately 24 biscuits, opened to air. 8. 1 oblong shaped brown bag with clear wrap-not labeled or dated. Observation of counter in kitchen on 06/09/2025 at 6:20 AM revealed the following: 9. 3 cookies were on the counter in a bag open to air, no date. In an interview on 06/10/2025 at 1:00 PM, the DM stated that all staff were responsible for ensuring items were labeled and dated. The DM stated every item opened, should have an open date in the refrigerator, freezer, and dry storage. The DM stated if food items were not properly labeled and dated, staff may be unaware of when the items were opened, increasing the risk of food spoilage and potential illness for residents. In an interview on 06/10/25 at 1:15 PM, DA B stated that all staff were responsible for ensuring items in the kitchen were covered, labeled, and dated and failure to do so could result in residents being served spoiled food, which could cause sickness. DA B stated the DM was responsible for ensuring staff was doing their job. In an interview on 6/11/2025 at 11:00 AM, DA C stated that all staff were responsible for making sure items in the kitchen were covered, labeled, and dated, and a possible negative outcome would be residents could receive bad food and get sick. Record review of Food Receiving and Storage Policy dated 8/1/2020 revealed the following: Foods will be received and stored by methods to minimize contamination and bacterial growth. Refrigerated foods are properly covered, labeled, and dated with a use by date. [NAME] them clearly to indicate the date by which the food shall be consumed or discarded. The day of preparation or day original container is opened shall be considered day 1, discard after three days unless otherwise indicated. Check expiration dates and use by dates to assure the dates are within acceptable parameters. Place food that is repackaged in a leak proof, pest proof, nonabsorbent, sanitary container with a tight-fitting lid. Label both the container and its lid with the common name of the contents, the date it was transferred to the new container, and the discard date. Record review of FDA Code dated 2022 revealed the following: Pathogens can contaminate and/or grow in food that is not stored properly.

Based on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 (Resident #30) of 15 residents reviewed for PASRR. The facility failed to perform a new PASRR level 1 assessment on Resident #30 due to diagnoses of bipolar disorder and PTSD. This failure could place residents at risk of not receiving needed services and support. Findings Included: Record review of Resident #30's admission record dated 06/11/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, bipolar disorder mixed severe (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings) and post-traumatic stress disorder (mental health condition caused by a traumatic event that affects your ability to function normally). The date listed for these two diagnoses was 08/30/24. Record review of Resident #30's MDS completed on 04/08/25 revealed a BIMS score of 12 which indicated moderately impaired cognition. Section I indicated Resident #12 had diagnoses that included Bipolar Disorder and PTSD. Record review of Resident #30's care plan completed on 04/09/25 revealed the following focus areas: The resident has a behavior problem easily agitated, short with staff rt bipolar disorder The resident uses antidepressant medication . r/t bipolar disorder The resident uses psychotropic medications . r/t Bipolar disorder. The resident has a mood problem r/t Bipolar disorder, PTSD Record review of Resident #30's active orders dated 06/10/25 revealed the following orders and start dates: Aripiprazole Oral Tablet 5 MG . Give 1 tablet by mouth at bedtime related to BIPOLAR DISORDER . 02/26/2025 Duloxetine HCI Oral Capsule Delayed Release Sprinkle 60 MG . Give 1 capsule by mouth at bedtime for antidepressant related to BIPOLAR DISORDER . 08/31/24 Record review of Resident #30's MISC tab in her EHR revealed her most recent psychiatry progress note was dated 06/06/25 and she was being treated for bipolar disorder and PTSD. Record review of Resident #30's PASRR level 1 assessment revealed it was performed on 08/29/24 and she was noted to be negative for mental illness. During an interview on 06/11/25 at 09:20 AM ADM stated not performing a new PASRR level 1 assessment on a resident with a qualifying diagnosis could result in a resident not receiving extra services they need. She stated DON was responsible for PASRR assessments. During an interview on 06/11/25 at 09:40 AM DON stated residents might miss out on services they need if they were not newly assessed based on a qualifying diagnosis. DON stated she thought if Resident #30 was screened as negative for mental illness prior to admission she did not need a new PASRR level 1 assessment despite having a qualifying diagnosis because she presumably had the diagnosis prior to admission and at the time of the original screening. During an interview on 06/11/25 at 10:32 AM DON stated she was responsible for PASRR level 1 screenings. During an interview on 06/11/25 at 10:44 AM with MHAE, whose phone number was provided by DON, she stated a bipolar disorder diagnosis would require the facility to conduct another PASRR level 1 assessment. MHAE stated this time the PASRR level 1 assessment would be positive for mental illness, which would prompt the mental health authority to come to the facility and reassess Resident #30 for eligibility for PASRR services. Record review of facility policy titled admission Criteria and dated March 2019 revealed no mention of re-screening residents based on qualifying diagnoses.

Based on interviews and record reviews the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission for 1 (Resident #103) of 15 residents reviewed for care planning. The facility failed to develop a baseline care plan for Resident 103 within 48 hours of her admission. This failure could place newly admitted residents at risk of not receiving effective, person-centered care. Findings Included: Record review of Resident #103's admission record dated 06/11/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, hypertensive heart disease (heart problems that occur due to high blood pressure), vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain), epilepsy (disorder that causes abnormal brain function, seizures), malignant neoplasm of nipple and areola of left breast (nipple cancer), Crohn's disease (inflammatory bowel disease resulting in abdominal pain, fatigue, diarrhea, and weight loss), and osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes or deficiency of calcium of vitamin D). Record review of Resident #103's EHR under the MDS tab revealed no comprehensive MDS assessments had been completed. Record review of Resident #103's EHR under the Care Plan tab revealed no care plan had been initiated. Record review of Resident #103's EHR under the Assmnts tab revealed no baseline care plan. Record review of Resident #103's EHR under the MISC tab revealed no baseline care plan. During an interview on 06/11/25 at 08:43 AM DON stated Resident #103 just got here (facility) and would not have a baseline care plan. She stated she would look in Resident #103's EHR. During an interview on 06/11/25 at 09:01 AM DON provided a copy of a baseline care plan for Resident #103 with a completion date of 06/11/25. During an interview on 06/11/25 at 09:20 AM ADM stated a resident not having a baseline care plan completed with in 48 hours of admission negatively impact the care they received. During an interview on 06/11/25 at 09:45 AM ADON stated a resident could be negatively impacted by not having a baseline care plan completed within 48 hours of admission. She stated, How would we care for them and know what baseline is and if they are improving or declining? During an interview on 06/11/25 at 10:02 AM ADM stated DON was responsible for completing baseline care plans. During an interview on 06/11/25 at 10:32 AM DON stated baseline care plans were part of the admission packet and should be completed by the charge nurse or the admitting nurse within 48 hours. She stated she did not know why Resident #103's baseline care plan was not completed within 48 hours of her admission. She stated she had trained the nurses in the facility on completing baseline care plans timely. DON stated staff might not identify needs of residents and residents might not have their needs met or addressed if a baseline care plan was not completed timely. Record review of facility policy title Care Plans-Baseline and dated March 2022 revealed the following: . A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (Resident #26, Resident #45, and Resident #46) of 17 residents reviewed for infection control. -LVN D failed to use the proper disinfecting wipes when disinfecting equipment used on residents. This deficient practice had the potential to place residents at risk by exposing them to care that could lead to the spread of viral infections, secondary infections, communicable diseases. Findings include: During an observation on 06/09/25 at 06:32 AM, LVN D performed a blood glucose check on Resident # 26 and did not clean glucometer after blood glucose check. During an observation on 06/09/25 at 06:36 AM, LVN D performed a blood glucose check on Resident # 46,. LVN did not clean the glucometer before or after blood glucose check for Resident #46. During an observation on 06/09/25 at 06:43 AM, LVN D took the glucometer that she (LVN D) just used with Resident #46 and went to Resident 46's roommate, Resident #45 and perform a blood glucose check without cleaning the glucometer in between the residents. During an interview on 06/09/25 at 12:08 PM, LVN D stated a negative outcome for not disinfecting the glucometer in between residents would lead to cross contamination and increase a risk for infection. During an interview on 06/11/25 at 08:33 AM, the ADON stated a negative outcome for not cleaning the glucometer in between residents could lead to infection control issues. During an interview on 06/11/25 at 08:48 AM, the DON stated a negative outcome would be contamination and an increased risk for infection. Record review of the facility -provided policy, titled, Obtaining a Fingerstick Glucose Level, revised October 2011, revealed the following: .3. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. .18. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. Record review of the facility- provided policy, titled, Blood Sampling-Capillary (Finger Sticks), revised September 2014, revealed the following: .General Guidelines 1. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. .8. Following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devices after each use.

Based on observations, interviews, and record reviews, the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 (Residents #1) of 6 residents reviewed for care plans. The facility failed to implement Resident #1's care plan to ensure Resident #1 was transferred and toileted with the assistance of 2 staff in order to ensure resident's safety. Resident #1 was transfered from her bed to wheelchair using a gait belt with the assistance of one person. This failure could place residents at risk of not receiving care and services related to their identified needs to maintain or reach their highest practicable physical, mental, and psychosocial wellbeing. The findings included: Resident #1 was a 69-y o female admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis, kidney failure and muscle wasting. Record review of Resident #1's comprehensive care plan dated 5/6/25 reflected Resident #1 was at risk for falls, required 2 persons assist for toileting, transfers and bed mobility. The goal of the care plan reflected The resident will maintain current level of function in ADLs through the review date. Interventions listed revealed: The resident required extensive assistance of 2 staff for toileting, bed mobility, and transfers. Record review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS score of 12 out of 15 which indicated cognition was moderately impaired. Section GG of the MDS documented transfers, toileting and bed mobility for Resident #1 was dependent- Helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. persons on 2 staff required maximum assistance with ADLs of toileting, bed mobility and transfers. Resident had 2 staff required for transfers, and toileting. In an interview on 6/4/25 at 10:10 am, the DON stated she expected all staff to review and follow the care plan recommendations. She stated the care plans were accessible on the front of each resident's chart. She stated if a resident could bear weight the resident was considered a 1 person assist and a one-person transfer. She stated that was how the MDS was scored and how the care plans reflected the MDS. She stated the MDS was scored after the nurses and CNAs provided the information on the resident and then the MDS calculated how much assistance the resident needed. She stated a resident was considered a one person transfer because the resident could bear weight and could participate or assist in helping with the transfers. The DON stated the consequences of not transferring residents correctly using the recommendations of the care plan would be injuries to the resident. In an observation and interview on 6/4/25 at 10:39 am, CNA A transferred Resident #1 from her bed to a wheelchair using a gait belt. CNA A toileted Resident #1 with no other staff assistance. Resident #1 was observed with left sided weakness of her arm. Resident #1 did not assist CNA A with the transfer. CNA A stated Resident #1 was a one-person transfer. CNA A stated she had always transferred Resident #1 by herself. CNA A stated Resident #1 was a left sided weakness so she could use her good side to assist with transfers. She stated Resident #1 did not weigh much so she could complete the transfer by herself. In an interview on 6/4/25 at 11:00 am, PTA B stated the facility had several residents who needed to be a 2 person transfer that were not a 2 person transfer at the present time. In an interview on 6/4/25 at 1:10 pm Resident #1 stated since she had been admitted to the facility, she had always been transferred with one person for the bathroom and getting out of the bed. She stated, It had always been with just one person. Resident #1 stated she had to go to the bathroom at least once every hour since she had been on dialysis. She stated when she needed to go, she had to go right then and could not wait. She stated she could not move her left side or assist at all. In an interview on 6/4/25 at 4:30 pm, CNA A stated Resident #1had been a one person transfer and a one person assist for toileting. She stated Resident #1 had left sided weakness, but she could use her right side to assist with the transfers. CNA A stated she had not been aware Resident #1 's care plan revealed she was a total dependence x's 2 and a two-person transfer and toilet. CNA A stated she had always transferred and toileted Resident #1 by herself. She stated all the facility staff only transfer Resident #1 as a one-person transfer. She stated she did not look at the care plan. She stated the care plan was available on the computer, but she had not looked at it. She stated when she was hired, she had been trained by the facility staff and had in-services on transfers since her hire. She stated the consequences of Resident #1 being transferred with only one person would be she could get hurt. In an interview on 6/4/25 at 5:00 pm, the DON stated she was not sure what Resident #1's assistance level would be, but it should be in the care plan. She stated the care a resident had gotten was driven by the lookback of 7 days in the MDS and the care level of residents could change every time the MDS was redone. She stated the nursing staff used the care plans to know how to care for resident. She stated the MDS drove the care plans and the care plans would change with every look back period. During exit conference on 6/4/25 at 6:45 pm, the ADM stated she had scheduled a training for facility staff for transfers with the therapy department and all care plans would be reviewed. Record review of facility's policy Care Plans, Comprehensive Person -Centered, dated March 2022, reflected. 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. The comprehensive care plan describes the services that are to be furnished to attain or maintain the residents highest practicable physical, mental and psychosocial well-being. Services provided for or arranged by the facility and outlined in the comprehensive service plan are provided by qualified persons. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem area s and their causes, and relevant clinical decision making.

Based on interviews and record review, it was determined the facility failed to ensure residents remained free from accidents, hazards, and each resident received adequate supervision and assistance when being monitored for 1 of 6 residents (Resident #2) reviewed for accident/hazards and supervision. LVN A, who was alone on the secured unit, failed to notice Resident #1 moving in his wheelchair down the hallway to Resident #2's room. LVN A heard a noise and thought someone fell . LVN A went to Resident #2's room and found Resident #1 hitting Resident #2 with the leg extension off of his wheelchair. Resident #2 was sent to the hospital and was found to have facial fractures and several lacerations requiring sutures. This deficient practice has the potential to affect all residents in the building who required supervision by allowing resident to resident interactions, falls, lacerations, fractures, and even death. The evidence is as follows: Resident #1 Record review of Resident #1's Face Sheet documented a [AGE] year old male who was admitted to the facility on [DATE], with the following Diagnoses: [REDACTED]. -Care Plan: impulsive behavior - cursing at staff/threatening to hit staff with cane, yelling at female residents, [MEDICAL CONDITION] drug use. -An admission MDS resident assessment, dated 2/2/2020, documented the resident can usually make himself understood and usually understands others, scored 11 of 15 on a mini-mental exam, disorganized thinking, no behavioral symptoms at this time, limited assistance by one staff for bed mobility, transfers and personal hygiene, required extensive assistance by one staff for dressing and toileting, totally dependent on one staff for bathing, uses a cane and a wheelchair at times, occasionally incontinent of bladder, had falls prior to admission, 63 inches tall, 115 pounds. -Nurses Notes documented the following: 2/14/2020 at 9:30 a.m. - resident hallucinating, stating car was broke down and had his five kids and needed help with car. Resident became very angry, cursing at staff and yelling and cussing in the dining room. Staff attempted to talk with resident and resident will not listen. Staff called spouse to attempt to calm resident and resident got more aggressive and verbally aggressive. Resident was left alone without anyone bothering him. continue to monitor. Spouse stated that's why she didn't want him home, cause he was abusive to her. 2/14/2020 at 2:30 p.m. - staff escorting resident to go out to smoke, resident became aggressive, attempting to hit staff with cane. Cane was removed from resident, resident very verbally and physically aggressive. 2/14/2020 at 7:15 p.m. - Resident had another resident's wheelchair, wheeling himself up and down hallway and in dining room. Staff attempted to redirect resident so wheelchair could be returned to other resident. Resident stood up, slinging wheelchair around and yelling at staff. This nurse and another nurse explained to resident the wheelchair needed to be returned to other resident. Resident visibly upset, nurse was able to redirect. 2/15/2020 at 10:00 a.m. - Resident verbally aggressive with staff, pacing the dining area, unable to redirect, resident making fist with both hands pacing the dining area, stating he does not want to be here, nurse attempted to give resident a PRN medication, Resident stated, leave me alone and I am not going to take nothing. Nurse unable to give medication. Nurse Practitioner called, give [MEDICATION NAME] 10 mg IM times one and [MEDICATION NAME] 5 mg by mouth twice a day. 2/19/2020 at 2:45 p.m. - CNA came in from smoking resident and informed nurse that resident was upset that he wanted to call his wife. Nurse dialed wife and informed resident's wife was on the phone. Resident spoke with wife on phone and was yelling for her to come get him and hung up. Resident became very angry yelling at female residents to get away from him. Nurse went to get cane because resident was swinging it, resident wouldn't give this nurse cane. CNA removed other residents from this resident and nurse called for help. Resident was combative, male resident offered this resident a cigarette and took resident to smoke. DON called nurse practitioner to inform, gave order for Zyprexia 10 mg IM now. 3/1/2020 at 8:00 p.m. - this nurse went into resident's room, attempted to administer medications, resident grabbed spoon from nurse and tossed on floor. NOTE: Record review revealed no issues of aggression toward Resident #2 or other residents. Resident #2 Record review of Resident #2's Face Sheet documented a [AGE] year old male who was admitted to the facility on [DATE], with the following Diagnoses: [REDACTED]. -Care Plan: documented Resident #2 was placed on the secure unit due to wandering behavior, impulsive behaviors - grabbed another resident's shirt and would not let go causing the resident to fall to the ground. -An annual MDS resident assessment, dated 2/20/2020, documented the resident scored 7 of 15 on a mini-mental exam, required extensive assistance by two staff for transfers and toileting, required extensive assistance by one staff for bed mobility, dressing and personal hygiene, totally dependent on one staff for bathing, used a wheelchair, incontinent of bladder, 65 inches tall and 237 pounds. Nurses Note documenting the incident on 3/4/2020 at 4:20 a.m. on the secured unit between Resident #1 (the aggressor) and Resident #2: Heard noise and walked down hall. Noise was coming from room at end of the hall. This resident (Resident #1) was standing over Resident #2 in room [ROOM NUMBER]A and hitting him with leg off of a wheelchair. This nurse got Resident #1 out of the room and into hall. Other nursing staff arrived. Resident #1 said, He's sleeping with my wife. I'm going to kill him. I'm going to kill him. Resident #1 was saying this while swinging mop bucket handle and wheelchair leg. Staff nurse stayed with Resident #1 until police arrived. Resident #1's wife notified, facility management here and know about altercation. Police department took Resident #1's medications and resident out of facility. Review of Hospital Records for Resident #2 documented the following: -CT of the Head or Brain - 3/2/2020 at 7:05 a.m. Multiple facial contusions Acute displaced fractures of the anterior and posterior walls of the right sinus cavity Acute mildly displaced [MEDICAL CONDITION] zygomatic arch (an arch formed by the zygomatic bone with the temporal bone) Acute displaced [MEDICAL CONDITION] of the left frontal sinus Acute displaced [MEDICAL CONDITION] wall of the left orbit (eye) Acute displaced [MEDICAL CONDITION] borders of the left orbit (eye) Acute displaced fractures of the superior/lateral midline aspect of the mandible (jaw) Physical Exam in emergency room - 3/2/2020 Skin: multiple lacerations about the face and scalp including: lateral to left eye - 4.7 cm Inferior to left eye - 2.4 cm Upper lip laceration - 2.2 cm - full thickness Midline lower lip/chin midline - 6.5 cm - full thickness left side of eye - 1.4.cm left side of head - 3.4 cm right side of head - 3.4 Right die of eye - 2.4 Right anterior scalp - 2.4 cm Right forehead - 1.1 cm During an interview on 3/4/2020 at 8:30 a.m., the Administrator stated Resident #2 was in bed asleep when Resident #1 hit him with the wheelchair leg. The Administrator stated Resident #1 would be up and down all throughout the night time. During an interview on 3/4/2020 at 10:25 a.m., CNA D stated when Resident #1 first came to the facility he was nice and then later on he would be sitting in a chair and just freak out for no reason CNA D stated Resident #1 would try and hit staff with his cane and would yell and cuss at staff. CNA D stated Resident #1 would wave his cane like he was going to hit them but the nurse took his cane away. CNA D stated Resident #1's behaviors were gradually getting worse. During an interview on 3/4/2020 at 4:20 p.m., LVN A stated the two CNAs were off of the secured unit changing a resident on the rehab hallway. LVN A stated she was sitting behind the desk charting on the secured unit when it sounded like someone fell . LVN A stated she found Resident #1 in Resident #2's room hitting him with the leg of his wheelchair.(NAME)stated she pushed Resident #1 out of the room but Resident #2 kept trying to get back in the room. LVN A stated she braced herself against the door and Resident #1 finally quit trying to get in. LVN A stated she was scared to death. LVN A stated Resident #2 was bleeding profusely and there was blood everywhere and it was the scariest thing she had ever seen. LVN A did not say what kind of assessment was completed on Resident #2 or what was done ot stop the bleeding. LVN A stated a lot of times Resident #1 would get mad at staff but never another resident. During an interview on 3/4/2020 at 4:55 p.m., Resident #2's son stated his father had just gotten out of ICU yesterday. Resident #2's son stated when the family would visit during the day, there was always staff who redirected residents who were going into each other's rooms so where were they that night. Resident #2 wanted to know where the supervision was when the nurse was not redirecting the resident who beat up his father. Resident #2's son stated, Where were the other staff at? One person on the secured unit was not enough. Resident #2's son stated the Administrator at the facility assured the family their father would receive the supervision around the clock to ensure he was safe and kept from harm. During an interview on 3/5/2020 at 2:58 p.m., CNA E stated there was a resident on the rehab hallway that needed to be changed so they (CNA E and CNA F) left the secured unit to change the resident. CNA E stated when they got back to the secure unit, Resident #1 was standing in the hallway. CNA E stated he asked Resident #1 what was going on and Resident #1 said he got in a fight with Resident #2. CNA E stated Resident #1 had a leg of a wheelchair in his hand and it had blood all over it. CNA E stated he tried to get into Resident #2's room but he would not open the door and he could not find the LVN working on the secured unit. CNA E stated he went to the other side of the building and got the other charge nurse to help and when they came back to the secured unit, Resident #2's door was open. CNA E stated there was blood everywhere in Resident #2's room and all over Resident #2's head. CNA E stated that night Resident #1 was up and down all night.

Based on interviews and record review, it was determined the facility failed to ensure that staff who provided direct services to residents had the appropriate competencies and skills sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 6 residents (Residents #1 and #2) whose care was reviewed in that: The facility failed to adequately staff the secured unit resulting in a resident to resident altercation which resulted in major injuries for Resident #2. LVN A, who was alone on the secured unit with 22 residents, failed to notice Resident #1 moving in his wheelchair down the hallway to Resident #2's room. LVN A, who was sitting at the nurses station charting, heard a noise and thought someone fell . LVN A went to Resident #2's room and found Resident #1 hitting Resident #2 with the leg extension off of his wheelchair. Resident #2 was sent to the hospital and was found to have facial fractures and several lacerations requiring sutures. CNA E and CNA F were off of the secured unit changing a resident on the rehab hallway. This failure could place all residents at risk for maintaining their safety and attaining the highest practicable physical, mental and psychosocial well-being. The evidence is as follows: Resident #1 Record review of Resident #1's Face Sheet documented a [AGE] year old male who was admitted to the facility on [DATE], with the following Diagnoses: [REDACTED]. -Care Plan: impulsive behavior - cursing at staff/threatening to hit staff with cane, yelling at female residents, [MEDICAL CONDITION] drug use. -An admission MDS resident assessment, dated 2/2/2020, documented the resident can usually make himself understood and usually understands others, scored 11 of 15 on a mini-mental exam, disorganized thinking, no behavioral symptoms at this time, limited assistance by one staff for bed mobility, transfers and personal hygiene, required extensive assistance by one staff for dressing and toileting, totally dependent on one staff for bathing, uses a cane and a wheelchair at times, occasionally incontinent of bladder, had falls prior to admission, 63 inches tall, 115 pounds. -Nurses Notes documented the following: 2/14/2020 at 9:30 a.m. - resident hallucinating, stating car was broke down and had his five kids and needed help with car. Resident became very angry, cursing at staff and yelling and cussing in the dining room. Staff attempted to talk with resident and resident will not listen. Staff called spouse to attempt to calm resident and resident got more aggressive and verbally aggressive. Resident was left alone without anyone bothering him. continue to monitor. Spouse stated that's why she didn't want him home, cause he was abusive to her. 2/14/2020 at 2:30 p.m. - staff escorting resident to go out to smoke, resident became aggressive, attempting to hit staff with cane. Cane was removed from resident, resident very verbally and physically aggressive. 2/14/2020 at 7:15 p.m. - Resident had another resident's wheelchair, wheeling himself up and down hallway and in dining room. Staff attempted to redirect resident so wheelchair could be returned to other resident. Resident stood up, slinging wheelchair around and yelling at staff. This nurse and another nurse explained to resident the wheelchair needed to be returned to other resident. Resident visibly upset, nurse was able to redirect. 2/15/2020 at 10:00 a.m. - Resident verbally aggressive with staff, pacing the dining area, unable to redirect, resident making fist with both hands pacing the dining area, stating he does not want to be here, nurse attempted to give resident a PRN medication, Resident stated, leave me alone and I am not going to take nothing. Nurse unable to give medication. Nurse Practitioner called, give [MEDICATION NAME] 10 mg IM times one and [MEDICATION NAME] 5 mg by mouth twice a day. 2/19/2020 at 2:45 p.m. - CNA came in from smoking resident and informed nurse that resident was upset that he wanted to call his wife. Nurse dialed wife and informed resident's wife was on the phone. Resident spoke with wife on phone and was yelling for her to come get him and hung up. Resident became very angry yelling at female residents to get away from him. Nurse went to get cane because resident was swinging it, resident wouldn't give this nurse cane. CNA removed other residents from this resident and nurse called for help. Resident was combative, male resident offered this resident a cigarette and took resident to smoke. DON called nurse practitioner to inform, gave order for Zyprexia 10 mg IM now. 3/1/2020 at 8:00 p.m. - this nurse went into resident's room, attempted to administer medications, resident grabbed spoon from nurse and tossed on floor. NOTE: Record review revealed no issues of aggression toward Resident #2 or other residents. Resident #2 Record review of Resident #2's Face Sheet documented a [AGE] year old male who was admitted to the facility on [DATE], with the following Diagnoses: [REDACTED]. -Care Plan: documented Resident #2 was placed on the secure unit due to wandering behavior, impulsive behaviors - grabbed another resident's shirt and would not let go causing the resident to fall to the ground. -An annual MDS resident assessment, dated 2/20/2020, documented the resident scored 7 of 15 on a mini-mental exam, required extensive assistance by two staff for transfers and toileting, required extensive assistance by one staff for bed mobility, dressing and personal hygiene, totally dependent on one staff for bathing, used a wheelchair, incontinent of bladder, 65 inches tall and 237 pounds. Nurses Note documenting the incident on 3/4/2020 at 4:20 a.m. on the secured unit between Resident #1 (the aggressor) and Resident #2: Heard noise and walked down hall. Noise was coming from room at end of the hall. This resident (Resident #1) was standing over Resident #2 in room [ROOM NUMBER]A and hitting him with leg off of a wheelchair. This nurse got Resident #1 out of the room and into hall. Other nursing staff arrived. Resident #1 said, He's sleeping with my wife. I'm going to kill him. I'm going to kill him. Resident #1 was saying this while swinging mop bucket handle and wheelchair leg. Staff nurse stayed with Resident #1 until police arrived. Resident #1's wife notified, facility management here and know about altercation. Police department took Resident #1's medications and resident out of facility. Review of Hospital Records for Resident #2 documented the following: -CT of the Head or Brain - 3/2/2020 at 7:05 a.m. Multiple facial contusions Acute displaced fractures of the anterior and posterior walls of the right sinus cavity Acute mildly displaced [MEDICAL CONDITION] zygomatic arch (an arch formed by the zygomatic bone with the temporal bone) Acute displaced [MEDICAL CONDITION] of the left frontal sinus Acute displaced [MEDICAL CONDITION] wall of the left orbit (eye) Acute displaced [MEDICAL CONDITION] borders of the left orbit (eye) Acute displaced fractures of the superior/lateral midline aspect of the mandible (jaw) Physical Exam in emergency room - 3/2/2020 Skin: multiple lacerations about the face and scalp including: lateral to left eye - 4.7 cm Inferior to left eye - 2.4 cm Upper lip laceration - 2.2 cm - full thickness Midline lower lip/chin midline - 6.5 cm - full thickness left side of eye - 1.4.cm left side of head - 3.4 cm right side of head - 3.4 Right die of eye - 2.4 Right anterior scalp - 2.4 cm Right forehead - 1.1 cm During an interview on 3/4/2020 at 8:30 a.m., the Administrator stated Resident #2 was in bed asleep when Resident #1 hit him with the wheelchair leg. The Administrator stated Resident #1 would be up and down all throughout the night time. During an interview on 3/4/2020 at 10:25 a.m., CNA D stated when Resident #1 first came to the facility he was nice and then later on he would be sitting in a chair and just freak out for no reason CNA D stated Resident #1 would try and hit staff with his cane and would yell and cuss at staff. CNA D stated Resident #1 would wave his cane like he was going to hit them but the nurse took his cane away. CNA D stated Resident #1's behaviors were gradually getting worse. During an interview on 3/4/2020 at 4:20 p.m., LVN A stated the two CNAs were off of the secured unit changing a resident on the rehab hallway. LVN A stated she was sitting behind the desk charting on the secured unit when it sounded like someone fell . LVN A stated she found Resident #1 in Resident #2's room hitting him with the leg of his wheelchair.(NAME)stated she pushed Resident #1 out of the room but Resident #2 kept trying to get back in the room. LVN A stated she braced herself against the door and Resident #1 finally quit trying to get in. LVN A stated she was scared to death. LVN A stated Resident #2 was bleeding profusely and there was blood everywhere and it was the scariest thing she had ever seen. LVN A did not say what kind of assessment was completed on Resident #2 or what was done to stop the bleeding. LVN A stated a lot of times Resident #1 would get mad at staff but never another resident. During an interview on 3/4/2020 at 4:55 p.m., Resident #2's son stated his father had just gotten out of ICU yesterday. Resident #2's son stated when the family would visit during the day, there was always staff who redirected residents who were going into each other's rooms so where were they that night. Resident #2 wanted to know where the supervision was when the nurse was not redirecting the resident who beat up his father. Resident #2's son stated, Where were the other staff at? One person on the secured unit was not enough. Resident #2's son stated the Administrator at the facility assured the family their father would receive the supervision around the clock to ensure he was safe and kept from harm. During an interview on 3/5/2020 at 2:58 p.m., CNA E stated there was a resident on the rehab hallway that needed to be changed so they (CNA E and CNA F) left the secured unit to change the resident. CNA E stated when they got back to the secure unit, Resident #1 was standing in the hallway. CNA E stated he asked Resident #1 what was going on and Resident #1 said he got in a fight with Resident #2. CNA E stated Resident #1 had a leg of a wheelchair in his hand and it had blood all over it. CNA E stated he tried to get into Resident #2's room but he would not open the door and could not find the LVN working on the secured unit. CNA E stated he went to the other side of the building and got the other charge nurse to help and when they came back to the secured unit, Resident #2's door was open. CNA E stated there was blood everywhere in Resident #2's room and all over Resident #2's head. CNA E stated that night Resident #1 was up and down all night.

Based on interview and record review, the facility failed to ensure that nurse aides demonstrated competency in basic skills and techniques necessary to care for residents requiring assistance with toileting. CNA A failed to ensure that Resident #3 's hands were free of grab bars prior to lifting her off of the toilet, causing Resident #3 's left hand to become caught in the grab bar, resulting in a fractured wrist. This deficient practice adversely affected one resident and has the potential to affect 52 residents residing in the facility requiring assistance with toileting. Findings include: Interview on 6/26/13 at 12:10 pm with Resident #3 revealed the resident was in the restroom when CNA A arrived to assist Resident #3. Resident #3 stated that CNA A seemed to be in a hurry. Resident #3 stated CNA A wanted " me to hold onto the grab bar located on the wall directly in front of the toilet " but Resident #3 was holding onto the grab bars located to the left and right of the toilet. Resident #3 stated " my left hand was caught in the grab bar ". Resident #3 stated " she jerked me and my arm caught in the rail and I hollered. " Resident #3 stated CNA A helped her to sit down on the toilet and then removed her hand from the rail. During an interview on 6/26/13 at 4:00 pm with CNA A, CNA A stated she was responded to the Resident #3 's call light when she heard the resident yelling. Upon arriving in Resident #3 ' s room, CNA A went into the restroom to assist Resident #3. CNA A stated she wanted Resident #3 to hold onto the grab bar on the wall in front of the toilet. CNA A stated that she was helping Resident #3 stand up when Resident #3 said " hand hand " . CNA A stated " I looked and saw her hand caught in the bar so I had her sit back down. I had to help her get her hand loose. She said that her hand hurt. I put her in bed. I told her I had to get a nurse to look at her hand. I went to the nurse 's station but no one was there. " CNA A stated that she had to go assist a resident with showering and forgot about Resident #3 's injury. CNA A stated that when she answered Resident #3 ' s call light, she was in a hurry because she had another resident waiting to shower. Review on 6/26/13 at 3:00 pm of Resident #3 's admission record indicates that Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review on 6/26/13 at 3:05 pm of Resident #3 's care plan dated 6/4/13 reveals " I require extensive assist of two for bed mobility, transfers, toileting (1-2), personal hygiene ... " Review on 6/26/13 at 3:10 pm of Resident #3 s MDS reveals in Section G, Functional Status that resident requires extensive assistance, two plus person physical assist for toilet use. Review on 6/26/13 at 11:40 am of facility 's Patient/Resident Incident/Accident Investigation Worksheet revealed " pt c/o of left wrist pain upon assessing res wrist this nurse found swelling to wrist pt c/o pain when wrist flexed ordered rcvd for left wrist xray." Worksheet is dated 6/3/13 at 11:45am. Worksheet further states " Resident was in bathroom. CNA went to answer light and assist resident to bed. During transfer resident insisted on using side grab bar instead of front, as encouraged by CNA. When CNA was assisting resident to transfer left hand fell between grab bar and became twisted. Nurse noted [MEDICAL CONDITION] to left wrist and called physician. Review on 6/26/13 at 4:40 pm of the facility 's Certified Nursing Assistant (CNA) Position Description reveals the following: Task #3 under " Essential Functions " states " Reports to the Charge/Staff Nurse any observations and pertinent information related to the care of the patient/resident." Task #2 under " General Patient/Resident Care " states " Ensures that patients/residents are approached in a kind, gently and friendly manner. " Task #1 under "Communication " states " Reports all changes in a patients/residents condition as soon as possible to the Charge/Staff Nurse. " Task #1 under " Professionalism " states " Makes decisions that reflect both knowledge and good judgment. According to information provided by the administrator on 6/26/13, facility census is 56 with 52 of those residents requiring assistance with toileting.

Based on observations, interviews and record reviews, it was determined the facility failed implement their policies for prohibiting incidents of neglect for 1 of 5 sampled residents (Resident #11), who had a pressure ulcer, when the facility: 1) Failed to consult with Resident #11's physician (or physician's assistance (PA)) when the resident developed a facility-acquired pressure ulcer. 2) Failed to ensure Resident #11 received the necessary care and services to prevent the worsening of the pressure ulcer. 3) Failed to conduct skin assessments to identify the pressure ulcer, identify an dressing had been applied (without a physician's orders [REDACTED]. On 10/30/11, Resident #11 was identified with a new Stage II facility-acquired pressure ulcer on the left buttocks. The physician was not consulted, although, an agency nurse provided treatment without a physician's orders [REDACTED].#11's pressure ulcer was identified to have yellow slough. (Slough is an indicator of at least a Stage III pressure ulcer.) Failure to ensure to immediately consult Resident #11's physician regarding a facility-acquired pressure ulcer, resulted in a nine day delay in the physician evaluating and providing a treatment(s) plan. As a result, Resident #11's pressure ulcer worsened. This facility failure to prohibit incidents of resident neglect related to skin assessments and wound care treatments not being completed timely, placed all 52 residents at risk of not receiving timely care and services. The evidence is as follows: 1. During an observation of incontinence care on 11/8/11 at 9:08 a.m., Resident #11 was found to have a [MEDICATION NAME] dressing to her left upper buttocks and 3 small red spots on the right buttocks which were not open. The dressing appeared to be an old dressing due to the dark brown color of the dressing. The dressing was curled up on one side, with no date or initials to indicate when the dressing was applied. 2. On 11/8/11 at 9:45 a.m., an observation was made of Resident #11's pressure sore with LVN "A" providing treatment. LVN "A" had measured the pressure ulcer and stated, "It measured 2.5 cm x 2 cm with a depth of 0.1 cm, the sore was unstageable because of the yellow slough." Note: The facility's policy and procedure for Wound Care - Staging of Pressure Ulcers, dated 6/2008 - described a Stage II pressure ulcer as a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound be, without slough. May also present as an intact or open/ruptured serum-filled blister. It further described a Stage II pressure ulcer as presenting as a shiny or dry shallow ulcer without slough or bruising. 3. During an interview on 11/8/11 at 9:10 a.m., Resident #11's husband stated the dressing was dirty and had been there for a long time. 4. During a follow up interview on 11/8/11 at 12:50 p.m., Resident #11's husband stated the last treatment on her bottom was over a week ago. 5. Review of Resident #11's clinical record revealed the following: - The face sheet documented she was admitted to the facility on [DATE], she was currently [AGE] years of age, and her [DIAGNOSES REDACTED]. - An admission MDS resident assessment, dated 9/30/11, documented the Resident #11 was unable to recall 2 of 3 words after cueing, and was unsure of the day of the week. It documented she required extensive assistance by two staff for bed mobility and transfers, and assistance by one staff member for locomotion in the facility, personal hygiene and bathing. It documented she was not steady - only able to stabilize with human assistance and used a wheelchair for mobility. It further documented she had an indwelling catheter, had a feeding tube, stood 66 inches tall, weighed 147 pounds and was at risk of developing pressure ulcers, but she had no pressure ulcers at that time. - A nurse's note, dated 10/30/11 at 12:30 a.m., completed by an agency nurse (RN "F"), documented Resident #11 had a "Stage II pressure ulcer left buttock, area cleansed, exuderm dressing applied, husband states, 'It's been there for a while, it's just getting worse.' Patient will be turned every two hours." The nurse's notes provided no evidence the physician had been consulted. 6. Review of the nursing 24-Hour Report Sheet, dated 10/30/11, documented Resident #11 had a Stage II decubitis to her left buttock. The form provided no evidence the physician had been consulted. 7. Further review of Resident #11's clinical record revealed there was no evidence a physician's phone order had been written for treatment of [REDACTED]. There was also no evidence of a physician's progress note addressing the pressure ulcer or any other pressure ulcer. 8. Attempts were made to interview the agency nurse (RN "F"), but without success. Review of a statement, completed by RN "F" (Agency Nurse who found pressure ulcer), dated 11/9/11, documented a " female black CNA came to get her and said Resident #11 had something on her coccyx and her husband wanted a nurse to look at it. RN "F" stated she went to Resident #11's room and assessed the resident. RN "F" stated the husband repeated that the sore had been there and was getting worse. RN "F" stated she cleansed the sore with wound cleanser, covered it with something (couldn't remember what) and passed it on to the oncoming nurse." RN "F's" statement provided no evidence she had consulted with Resident #11's physician regarding the pressure ulcer. 9. During an interview on 11/9/11 at 3:48 p.m., Resident #11's PA stated she was informed of the pressure ulcer to Resident #11 buttocks on 11/8/11. She stated 11/8/11 was when she was first made aware of the skin issue with Resident #11. 10. Additional review of Resident 11's clinical record revealed the following: - A Braden Scale for Predicting Pressure Sore Risk, dated 10/3/11, documented a score of 16, which placed Resident #11 at risk of the development of a pressure sore. - There were two physician's telephone orders for preventative care to reduce the risk of pressure ulcer development. One order, dated 9/24/11, documented to apply Medspetic to buttock and coccyx area as needed. A second order, dated 9/26/11, documented to check buttocks/coccyx daily for skin breakdown. 11. Review of Resident #11's Wound Treatment & Progress Record documented for September/2011, documented on 9/24/11 - treatment - Medspetic to buttocks/coccyx PRN (as needed), but there was no documentation this was provided during the month of September 2011. 12. Review of the Treatment Flowsheet for Resident #11 for November/2011, documented to apply Medspetic to buttocks and coccyx PRN, but there was no documentation this was provided during the month of November 2011. It also documented to check buttock and coccyx daily, but failed to have documentation of any check being conducted from November 1st through the 6th. 13. Review of the Weekly Skin Documentation Sheets for Resident #11 revealed the following; - 10/3/11- skin is intact, warm and dry with fair turgor, no [MEDICAL CONDITION], - 10/10/11- skin is intact, warm and dry with fair turgor, no [MEDICAL CONDITION], - 10/17/11- skin is intact, warm and dry with fair turgor, no [MEDICAL CONDITION], and - 10/24/11- skin is intact, warm and dry with fair turgor, no [MEDICAL CONDITION]. - No other weekly skin assessments were available. 14. During a follow-up interview on 11/8/11 at 10:00 a.m., LVN "A" stated the skin assessment book was not current. She stated she had been the 6:00 a.m. to 2:00 p.m. nurse on Golden Village for the past month. She stated, "I am not the Wound Care nurse. We are so unorganized; I just don't want to take the fall for this. When I did wound care, I was on top of things but it is not my responsibility now." She stated there should be a skin assessment sheet completed weekly for every resident in the facility but she did not think any skin assessments had been completed for the month of November 2011. 15. During an interview on 11/8/11 at 9:50 a.m., CNA "B" stated Resident #11 had the pressure sore on her bottom when she was transferred on this side of the facility (from Angel to Golden Village). She stated she thought the facility was aware of the pressure sore so she did not report it. 16. During an interview on 11/8/11 at 2:16 p.m., the ADON stated Resident #11 was scheduled to receive a shower three times a week. She stated if a skin issue was found by a CNA during a resident's shower, her expectation would be that the CNA would inform the Charge Nurse. She stated she was not aware Resident #11 had a pressure sore, as she was aware only 2 residents in the facility had pressure sores. 17. Record review of the Shower Schedule Sheets, received from the facility on 11/10/11, documented Resident #11 received a shower in November 2011 on the following dates: 1st, 3rd, 4th and the 7th, but no documentation was found of any skin issues. 18. During an interview on 11/10/11 at 1:30 p.m., CNA "E" stated she had taken care of Resident #11 when she was on Angel Village. CNA "E" stated she remembered a small red spot on Resident #11's buttocks, applied [MEDICATION NAME] on the spot and reported the skin issue to the Charge Nurse. 19. During an interview on 11/8/11 at 3:56 p.m., CNA "C" stated she had taken care of Resident #11 and was aware of the sore on her bottom. CNA "C" stated she would place [MEDICATION NAME] on the sore. She stated the resident resided on Angel Village when she was admitted but was moved to Golden Village. 20. During an interview on 11/8/11 at 4:00 p.m., LVN "D" stated Resident #11 had been residing on Golden Village for approximately 2 weeks. She stated she was not aware of any skin breakdown on Resident #11 but she had never checked her because the Wound Care nurse does the skin assessments. She stated no staff member had ever reported to her any skin breakdown on Resident #11. 21. Review of a written statement by the Corporate RN, dated 11/9/11 at 11:00 a.m., documented the following: I was informed on 11/8/11 by the DON that a resident had a stage II to left buttocks. This wound was identified on 10/30/11 by an agency nurse per nursing notes and put on 24 hour report on 10/30/11. Per documentation, no further treatments were done on this wound until 11/8/11. I observed the wound on 11/9/11 after the resident had been given a shower. Wound presents as a stage II, partial thickness skin loss, slough covering approximately 75% of wound. 22. Review of the facility's Wound Care Polices and Procedures - Pressure Ulcers, revised 6/2008, documented the following: a. Policy - Pressure ulcers will be assessed and treated in accordance with generally accepted guidelines. i) Procedures: (1)Evaluate the pressure ulcer initially for location, stage, size, sinus tracts, undermining, tunneling, exudate, necrotic tissue, and the presence and or absence of granulation tissue and [MEDICATION NAME]. (2) Re-evaluate pressure ulcers at least weekly. If the patient's/resident's condition or the condition of the wound deteriorates, or if there is no significant progress within a reasonable time frame, the treatment plan should be re-evaluated. ii) Subject: Licensed Nurse Skin Checks b. Policy: All patients/residents will have a thorough weekly skin assessment performed by a Licensed Nurse. i) Procedures: (1) Weekly, the Licensed Nurse performs a head to toe check of the patient's/resident's skin, paying particular attention to: (a) The surfaces of the skin that come in contact with the bed and chair. (b) Bony prominence's (heels, tailbone, shoulder blades, elbows, back of the head, etc.) (c) The surfaces of the skin that come in contact with any orthotic device, tube, brace or positioning device. (d) Skin folds ii) Observing for redness (check for blanching and document blanchable, or non-blanchable redness), rashes, bruising and open areas. iii) Report any significant abnormal findings to the patient's/resident's physician and patient/resident contact person. iv) Document - - The check was performed is denoted on the Treatment Administration Record or the Weekly Skin Assessment Sheets. - Abnormal findings in the Nurses's Notes or to be documented on the back of the treatment sheet if space allows. - Actions taken in the Nurse's Notes, along with summary of all notified with their responses. 23. Review of the Resident Census and Conditions of Residents (CMS Form 672), dated 11/7/11, documented 2 residents with pressure ulcers. 24. Review of the list of residents recently discharged from the facility, dated 11/7/11, documented two residents discharged with pressure ulcers.

Based on observations, interviews and record reviews, it was determined the facility failed implement their policies for prohibiting incidents of neglect for 1 of 5 sampled residents (Resident #11), who had a pressure ulcer, when the facility: 1) Failed to consult with Resident #11's physician (or physician's assistance (PA)) when the resident developed a facility-acquired pressure ulcer. 2) Failed to ensure Resident #11 received the necessary care and services to prevent the worsening of the pressure ulcer. 3) Failed to conduct skin assessments to identify the pressure ulcer, identify a dressing had been applied (without a physician's orders [REDACTED]. On 10/30/11, Resident #11 was identified with a new Stage II facility-acquired pressure ulcer on the left buttocks. The physician was not consulted, although, an agency nurse provided treatment without a physician's orders [REDACTED].#11's pressure ulcer was identified to have yellow slough. (Slough is an indicator of at least a Stage III pressure ulcer.) Failure to ensure to immediately consult Resident #11's physician regarding a facility-acquired pressure ulcer, resulted in a nine day delay in the physician evaluating and providing a treatment(s) plan. As a result, Resident #11's pressure ulcer worsened. This facility failure to prohibit incidents of resident neglect related to skin assessments and wound care treatments not being completed timely, placed all 52 residents at risk of not receiving timely care and services. The evidence is as follows: 1. Review of the facility submitted Policy and Procedure titled, "What You Need to Know" Abuse Prohibition, revised 2/2008, documented the following: Policy: The facility's leadership prohibits neglect, mental or physical abuse, including involuntary seclusion and misappropriation of a patient's/resident's property and/or funds. - Component IV: Identification: a. Staff members identify and assess suspected or alleged reports of abuse or neglect, focusing on objective and observable evidence, such as suspicious bruising, witness reports regarding unusual occurrences or patterns or trends of potential abuse or neglect. - Types of abuse include but are not limited to Neglect: Failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness. 2. Review of the facility's Wound Care Polices and Procedures - Pressure Ulcers, revised 6/2008, documented the following: Policy - Pressure ulcers will be assessed and treated in accordance with generally accepted guidelines. i) Procedures: (1)Evaluate the pressure ulcer initially for location, stage, size, sinus tracts, undermining, tunneling, exudate, necrotic tissue, and the presence and or absence of granulation tissue and [MEDICATION NAME]. (2) Re-evaluate pressure ulcers at least weekly. If the patient's/resident's condition or the condition of the wound deteriorates, or if there is no significant progress within a reasonable time frame, the treatment plan should be re-evaluated. ii) Subject: Licensed Nurse Skin Checks b. Policy: All patients/residents will have a thorough weekly skin assessment performed by a Licensed Nurse. iii) Procedures: (1) Weekly, the Licensed Nurse performs a head to toe check of the patient's/resident's skin, paying particular attention to: (a) The surfaces of the skin that come in contact with the bed and chair. (b) Bony prominence's (heels, tailbone, shoulder blades, elbows, back of the head, etc.) (c) The surfaces of the skin that come in contact with any orthotic device, tube, brace or positioning device. (d) Skin folds iv) Observe for redness (check for blanching and document blanchable, or non-blanchable redness), rashes, bruising and open areas. v) Report any significant abnormal findings to the patient's/resident's physician and patient/resident contact person. vi) Document - - The check was performed is denoted on the Treatment Administration Record or the Weekly Skin Assessment Sheets. - Abnormal findings in the Nurses's Notes or to be documented on the back of the treatment sheet if space allows. - Actions taken in the Nurse's Notes, along with summary of all notified with their responses. 3. During an observation of incontinence care on 11/8/11 at 9:08 a.m., Resident #11 was found to have a [MEDICATION NAME] dressing to her left upper buttocks and 3 small red spots on the right buttocks which were not open. The dressing appeared to be an old dressing due to the dark brown color of the dressing. The dressing was curled up on one side, with no date or initials to indicate when the dressing was applied. 4. On 11/8/11 at 9:45 a.m., an observation was made of Resident #11's pressure sore with LVN "A" providing treatment. LVN "A" had measured the pressure ulcer and stated, "It measured 2.5 cm x 2 cm with a depth of 0.1 cm, the sore was unstageable because of the yellow slough." Note: The facility's policy and procedure for Wound Care - Staging of Pressure Ulcers, dated 6/2008 - described a Stage II pressure ulcer as a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound be, without slough. May also present as an intact or open/ruptured serum-filled blister. It further described a Stage II pressure ulcer as presenting as a shiny or dry shallow ulcer without slough or bruising. 5. During an interview on 11/8/11 at 9:10 a.m., Resident #11's husband stated the dressing was dirty and had been there for a long time. 6. During a follow up interview on 11/8/11 at 12:50 p.m., Resident #11's husband stated the last treatment on her bottom was over a week ago. 6. Review of Resident #11's clinical record revealed the following: - The face sheet documented she was admitted to the facility on [DATE], she was currently [AGE] years of age, and her [DIAGNOSES REDACTED]. - An admission MDS resident assessment, dated 9/30/11, documented the Resident #11 was unable to recall 2 of 3 words after cueing, and was unsure of the day of the week. It documented she required extensive assistance by two staff for bed mobility and transfers, and assistance by one staff member for locomotion in the facility, personal hygiene and bathing. It documented she was not steady - only able to stabilize with human assistance and used a wheelchair for mobility. It further documented she had an indwelling catheter, had a feeding tube, stood 66 inches tall, weighed 147 pounds and was at risk of developing pressure ulcers, but she had no pressure ulcers at that time. - A nurse's note, dated 10/30/11 at 12:30 a.m., completed by an agency nurse (RN "F"), documented Resident #11 had a "Stage II pressure ulcer left buttock, area cleansed, exuderm dressing applied, husband states, 'It's been there for a while, it's just getting worse.' Patient will be turned every two hours." The nurse's notes provided no evidence the physician had been consulted. 8. Review of the nursing 24-Hour Report Sheet, dated 10/30/11, documented Resident #11 had a Stage II decubitis to her left buttock. The form provided no evidence the physician had been consulted. 9. Further review of Resident #11's clinical record revealed there was no evidence a physician's phone order had been written for treatment of [REDACTED]. There was also no evidence of a physician's progress note addressing the pressure ulcer or any other pressure ulcer. 10. Attempts were made to interview the agency nurse (RN "F"), but without success. Review of a statement, completed by RN "F" (Agency Nurse who found pressure ulcer), dated 11/9/11, documented a " female black CNA came to get her and said Resident #11 had something on her coccyx and her husband wanted a nurse to look at it. RN "F" stated she went to Resident #11's room and assessed the resident. RN "F" stated the husband repeated that the sore had been there and was getting worse. RN "F" stated she cleansed the sore with wound cleanser, covered it with something (couldn't remember what) and passed it on to the oncoming nurse." RN "F's" statement provided no evidence she had consulted with Resident #11's physician regarding the pressure ulcer. 11. During an interview on 11/9/11 at 3:48 p.m., Resident #11's PA stated she was informed of the pressure ulcer to Resident #11 buttocks on 11/8/11. She stated 11/8/11 was when she was first made aware of the skin issue with Resident #11. 12. Additional review of Resident 11's clinical record revealed the following: - A Braden Scale for Predicting Pressure Sore Risk, dated 10/3/11, documented a score of 16, which placed Resident #11 at risk of the development of a pressure sore. - There were two physician's telephone orders for preventative care to reduce the risk of pressure ulcer development. One order, dated 9/24/11, documented to apply Medspetic to buttock and coccyx area as needed. A second order, dated 9/26/11, documented to check buttocks/coccyx daily for skin breakdown. 13. Review of Resident #11's Wound Treatment & Progress Record documented for September/2011, documented on 9/24/11 - treatment - Medspetic to buttocks/coccyx PRN (as needed), but there was no documentation this was provided during the month of September 2011. 14. Review of the Treatment Flowsheet for Resident #11 for November/2011, documented to apply Medspetic to buttocks and coccyx PRN, but there was no documentation this was provided during the month of November 2011. It also documented to check buttock and coccyx daily, but failed to have documentation of any check being conducted from November 1st through the 6th. 15. Review of the Weekly Skin Documentation Sheets for Resident #11 revealed the following; - 10/3/11- skin is intact, warm and dry with fair turgor, no [MEDICAL CONDITION], - 10/10/11- skin is intact, warm and dry with fair turgor, no [MEDICAL CONDITION], - 10/17/11- skin is intact, warm and dry with fair turgor, no [MEDICAL CONDITION], and - 10/24/11- skin is intact, warm and dry with fair turgor, no [MEDICAL CONDITION]. - No other weekly skin assessments were available. 16. During a follow-up interview on 11/8/11 at 10:00 a.m., LVN "A" stated the skin assessment book was not current. She stated she had been the 6:00 a.m. to 2:00 p.m. nurse on Golden Village for the past month. She stated, "I am not the Wound Care nurse. We are so unorganized; I just don't want to take the fall for this. When I did wound care, I was on top of things but it is not my responsibility now." She stated there should be a skin assessment sheet completed weekly for every resident in the facility but she did not think any skin assessments had been completed for the month of November 2011. 17. During an interview on 11/8/11 at 9:50 a.m., CNA "B" stated Resident #11 had the pressure sore on her bottom when she was transferred on this side of the facility (from Angel to Golden Village). She stated she thought the facility was aware of the pressure sore so she did not report it. 18. During an interview on 11/8/11 at 2:16 p.m., the ADON stated Resident #11 was scheduled to receive a shower three times a week. She stated if a skin issue was found by a CNA during a resident's shower, her expectation would be that the CNA would inform the Charge Nurse. She stated she was not aware Resident #11 had a pressure sore, as she was aware only 2 residents in the facility had pressure sores. 19. Record review of the Shower Schedule Sheets, received from the facility on 11/10/11, documented Resident #11 received a shower in November 2011 on the following dates: 1st, 3rd, 4th and the 7th, but no documentation was found of any skin issues. 20. During an interview on 11/10/11 at 1:30 p.m., CNA "E" stated she had taken care of Resident #11 when she was on Angel Village. CNA "E" stated she remembered a small red spot on Resident #11's buttocks, applied [MEDICATION NAME] on the spot and reported the skin issue to the Charge Nurse. 21. During an interview on 11/8/11 at 3:56 p.m., CNA "C" stated she had taken care of Resident #11 and was aware of the sore on her bottom. CNA "C" stated she would place [MEDICATION NAME] on the sore. She stated the resident resided on Angel Village when she was admitted but was moved to Golden Village. 22. During an interview on 11/8/11 at 4:00 p.m., LVN "D" stated Resident #11 had been residing on Golden Village for approximately 2 weeks. She stated she was not aware of any skin breakdown on Resident #11 but she had never checked her because the Wound Care nurse does the skin assessments. She stated no staff member had ever reported to her any skin breakdown on Resident #11. 23. Review of a written statement by the Corporate RN, dated 11/9/11 at 11:00 a.m., documented the following: I was informed on 11/8/11 by the DON that a resident had a stage II to left buttocks. This wound was identified on 10/30/11 by an agency nurse per nursing notes and put on 24 hour report on 10/30/11. Per documentation, no further treatments were done on this wound until 11/8/11. I observed the wound on 11/9/11 after the resident had been given a shower. Wound presents as a stage II, partial thickness skin loss, slough covering approximately 75% of wound. 24. Review of the Resident Census and Conditions of Residents (CMS Form 672), dated 11/7/11, documented 2 residents with pressure ulcers. 25. Review of the list of residents recently discharged from the facility, dated 11/7/11, documented two residents discharged with pressure ulcers.

Based on observations, interviews and record review, it was determined the facility: 1) Failed to ensure 1 of 2 residents (Resident #11), who developed an in-house acquired and avoidable pressure ulcer, was provided the necessary care and services to prevent pressure ulcers from developing, and 2) Failed to ensure 1 of 5 residents (Resident #11) was provided the necessary care and services to prevent the worsening of an existing pressure ulcer. 1) Failed to consult with Resident #11's physician (or physician's assistance (PA)) when the resident developed a facility-acquired pressure ulcer. 2) Failed to ensure Resident #11 received the necessary care and services to prevent the worsening of the pressure ulcer. 3) Failed to conduct skin assessments to identify the pressure ulcer, identify a dressing had been applied (without a physician's orders [REDACTED]. On 10/30/11, Resident #11 was identified with a new Stage II facility-acquired pressure ulcer on the left buttocks. The physician was not consulted, although, an agency nurse provided treatment without a physician's orders [REDACTED].#11's pressure ulcer was identified to have yellow slough. (Slough is an indicator of at least a Stage III pressure ulcer.) Failure to ensure to immediately consult Resident #11's physician regarding a facility-acquired pressure ulcer, resulted in a nine day delay in the physician evaluating and providing a treatment(s) plan. As a result, Resident #11's pressure ulcer worsened. Failure to conduct timely skin assessments, consult with the physician, as needed, and provided wound care treatments, placed three other residents the facility identified as having pressure ulcers, at risk for development of new pressure sores, deterioration of existing pressure ulcers and [MEDICAL CONDITION]. The evidence is as follows: 1. During an observation of incontinence care on 11/8/11 at 9:08 a.m., Resident #11 was found to have a [MEDICATION NAME] dressing to her left upper buttocks and 3 small red spots on the right buttocks which were not open. The dressing appeared to be an old dressing due to the dark brown color of the dressing. The dressing was curled up on one side, with no date or initials to indicate when the dressing was applied. 2. On 11/8/11 at 9:45 a.m., an observation was made of Resident #11's pressure sore with LVN "A" providing treatment. LVN "A" had measured the pressure ulcer and stated, "It measured 2.5 cm x 2 cm with a depth of 0.1 cm, the sore was unstageable because of the yellow slough." Note: The facility's policy and procedure for Wound Care - Staging of Pressure Ulcers, dated 6/2008 - described a Stage II pressure ulcer as a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound be, without slough. May also present as an intact or open/ruptured serum-filled blister. It further described a Stage II pressure ulcer as presenting as a shiny or dry shallow ulcer without slough or bruising. 3. During an interview on 11/8/11 at 9:10 a.m., Resident #11's husband stated the dressing was dirty and had been there for a long time. 4. During a follow up interview on 11/8/11 at 12:50 p.m., Resident #11's husband stated the last treatment on her bottom was over a week ago. 5. Review of Resident #11's clinical record revealed the following: - The face sheet documented she was admitted to the facility on [DATE], she was currently [AGE] years of age, and her [DIAGNOSES REDACTED]. - An admission MDS resident assessment, dated 9/30/11, documented the Resident #11 was unable to recall 2 of 3 words after cueing, and was unsure of the day of the week. It documented she required extensive assistance by two staff for bed mobility and transfers, and assistance by one staff member for locomotion in the facility, personal hygiene and bathing. It documented she was not steady - only able to stabilize with human assistance and used a wheelchair for mobility. It further documented she had an indwelling catheter, had a feeding tube, stood 66 inches tall, weighed 147 pounds and was at risk of developing pressure ulcers, but she had no pressure ulcers at that time. - A nurse's note, dated 10/30/11 at 12:30 a.m., completed by an agency nurse (RN "F"), documented Resident #11 had a "Stage II pressure ulcer left buttock, area cleansed, exuderm dressing applied, husband states, 'It's been there for a while, it's just getting worse.' Patient will be turned every two hours." The nurse's notes provided no evidence the physician had been consulted. 6. Review of the nursing 24-Hour Report Sheet, dated 10/30/11, documented Resident #11 had a Stage II decubitis to her left buttock. The form provided no evidence the physician had been consulted. 7. Further review of Resident #11's clinical record revealed there was no evidence a physician's phone order had been written for treatment of [REDACTED]. There was also no evidence of a physician's progress note addressing the pressure ulcer or any other pressure ulcer. 8. Attempts were made to interview the agency nurse (RN "F"), but without success. Review of a statement, completed by RN "F" (Agency Nurse who found pressure ulcer), dated 11/9/11, documented a " female black CNA came to get her and said Resident #11 had something on her coccyx and her husband wanted a nurse to look at it. RN "F" stated she went to Resident #11's room and assessed the resident. RN "F" stated the husband repeated that the sore had been there and was getting worse. RN "F" stated she cleansed the sore with wound cleanser, covered it with something (couldn't remember what) and passed it on to the oncoming nurse." RN "F's" statement provided no evidence she had consulted with Resident #11's physician regarding the pressure ulcer. 9. During an interview on 11/9/11 at 3:48 p.m., Resident #11's PA stated she was informed of the pressure ulcer to Resident #11 buttocks on 11/8/11. She stated 11/8/11 was when she was first made aware of the skin issue with Resident #11. 10. Additional review of Resident 11's clinical record revealed the following: - A Braden Scale for Predicting Pressure Sore Risk, dated 10/3/11, documented a score of 16, which placed Resident #11 at risk of the development of a pressure sore. - There were two physician's telephone orders for preventative care to reduce the risk of pressure ulcer development. One order, dated 9/24/11, documented to apply Medspetic to buttock and coccyx area as needed. A second order, dated 9/26/11, documented to check buttocks/coccyx daily for skin breakdown. 11. Review of Resident #11's Wound Treatment & Progress Record documented for September/2011, documented on 9/24/11 - treatment - Medspetic to buttocks/coccyx PRN (as needed), but there was no documentation this was provided during the month of September 2011. 12. Review of the Treatment Flowsheet for Resident #11 for November/2011, documented to apply Medspetic to buttocks and coccyx PRN, but there was no documentation this was provided during the month of November 2011. It also documented to check buttock and coccyx daily, but failed to have documentation of any check being conducted from November 1st through the 6th. 13. Review of the Weekly Skin Documentation Sheets for Resident #11 revealed the following; - 10/3/11- skin is intact, warm and dry with fair turgor, no [MEDICAL CONDITION], - 10/10/11- skin is intact, warm and dry with fair turgor, no [MEDICAL CONDITION], - 10/17/11- skin is intact, warm and dry with fair turgor, no [MEDICAL CONDITION], and - 10/24/11- skin is intact, warm and dry with fair turgor, no [MEDICAL CONDITION]. - No other weekly skin assessments were available. 14. During a follow-up interview on 11/8/11 at 10:00 a.m., LVN "A" stated the skin assessment book was not current. She stated she had been the 6:00 a.m. to 2:00 p.m. nurse on Golden Village for the past month. She stated, "I am not the Wound Care nurse. We are so unorganized; I just don't want to take the fall for this. When I did wound care, I was on top of things but it is not my responsibility now." She stated there should be a skin assessment sheet completed weekly for every resident in the facility but she did not think any skin assessments had been completed for the month of November 2011. 15. During an interview on 11/8/11 at 9:50 a.m., CNA "B" stated Resident #11 had the pressure sore on her bottom when she was transferred on this side of the facility (from Angel to Golden Village). She stated she thought the facility was aware of the pressure sore so she did not report it. 16. During an interview on 11/8/11 at 2:16 p.m., the ADON stated Resident #11 was scheduled to receive a shower three times a week. She stated if a skin issue was found by a CNA during a resident's shower, her expectation would be that the CNA would inform the Charge Nurse. She stated she was not aware Resident #11 had a pressure sore, as she was aware only 2 residents in the facility had pressure sores. 17. Record review of the Shower Schedule Sheets, received from the facility on 11/10/11, documented Resident #11 received a shower in November 2011 on the following dates: 1st, 3rd, 4th and the 7th, but no documentation was found of any skin issues. 18. During an interview on 11/10/11 at 1:30 p.m., CNA "E" stated she had taken care of Resident #11 when she was on Angel Village. CNA "E" stated she remembered a small red spot on Resident #11's buttocks, applied [MEDICATION NAME] on the spot and reported the skin issue to the Charge Nurse. 19. During an interview on 11/8/11 at 3:56 p.m., CNA "C" stated she had taken care of Resident #11 and was aware of the sore on her bottom. CNA "C" stated she would place [MEDICATION NAME] on the sore. She stated the resident resided on Angel Village when she was admitted but was moved to Golden Village. 20. During an interview on 11/8/11 at 4:00 p.m., LVN "D" stated Resident #11 had been residing on Golden Village for approximately 2 weeks. She stated she was not aware of any skin breakdown on Resident #11 but she had never checked her because the Wound Care nurse does the skin assessments. She stated no staff member had ever reported to her any skin breakdown on Resident #11. 21. Review of a written statement by the Corporate RN, dated 11/9/11 at 11:00 a.m., documented the following: I was informed on 11/8/11 by the DON that a resident had a stage II to left buttocks. This wound was identified on 10/30/11 by an agency nurse per nursing notes and put on 24 hour report on 10/30/11. Per documentation, no further treatments were done on this wound until 11/8/11. I observed the wound on 11/9/11 after the resident had been given a shower. Wound presents as a stage II, partial thickness skin loss, slough covering approximately 75% of wound. 22. Review of the facility's Wound Care Policy and Procedures - Staging of pressure ulcers - National Pressure Ulcer Advisor Panel - NPUAP, revised 6/2008, documented the following: - Pressure Ulcer Definition - "A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. - Pressure Ulcer Stages Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. A Stage I area may be difficult to detect in individuals with dark skin tones. Stage II: Partial Thickness loss of dermis presenting as a shallow open ulcer with a red pink wound be, without slough. May also present as an intact or open/ruptured serum-filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a Stage III pressure ulcer varied by anatomical location. Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further Description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. 23. Review of the Resident Censes and Conditions of Residents (CMS Form 672), dated 11/7/11, documented 2 residents with pressure ulcers. 24. Review of the list of residents recently discharged from the facility, dated 11/7/11, documented two residents discharged with pressure ulcers.

Based on interviews and record reviews, it was determined the facility failed to ensure 1 of 15 sampled residents' (Resident #11) physician was consulted when the resident experienced a change of condition. On 10/30/11, Resident #11 was identified with a new Stage II facility-acquired pressure ulcer on the left buttocks. The physician was not consulted, although, an agency nurse provided treatment without a physician's orders [REDACTED]. (Slough is an indicator of at least a Stage III pressure ulcer.) Failure to immediately consult Resident #11's physician regarding a facility-acquired pressure ulcer, resulted in a nine day delay in the physician evaluating and providing a treatment(s) order. As a result, Resident #11's pressure ulcer worsened. Failure to ensure a resident's attending physician is immediately consulted when a resident experiences a change of condition placed all 52 residents at risk of not receiving timely evaluation and treatment. The evidence is as follows: 1. During an observation of incontinence care on 11/8/11 at 9:08 a.m., Resident #11 was found to have a [MEDICATION NAME] dressing to her left upper buttocks and 3 small red spots on the right buttocks which were not open. The dressing appeared to be an old dressing due to the dark brown color of the dressing. The dressing was curled up on one side, with no date or initials to indicate when the dressing was applied. 2. On 11/8/11 at 9:45 a.m., an observation was made of Resident #11's pressure sore with LVN "A" providing treatment. LVN "A" had measured the pressure ulcer and stated, "It measured 2.5 cm x 2 cm with a depth of 0.1 cm, the sore was unstageable because of the yellow slough." 3. During an interview on 11/8/11 at 9:10 a.m., Resident #11's husband stated the dressing was dirty and had been there for a long time. 4. During a follow up interview on 11/8/11 at 12:50 p.m., Resident #11's husband stated the last treatment on her bottom was over a week ago. 5. Review of Resident #11's clinical record revealed the following: - The face sheet documented she was admitted to the facility on [DATE], she was currently [AGE] years of age, and her [DIAGNOSES REDACTED]. - A nurse's note, dated 10/30/11 at 12:30 a.m., completed by an agency nurse (RN "F"), documented Resident #11 had a "Stage II pressure ulcer left buttock, area cleansed, exuderm dressing applied, husband states, 'It's been there for a while, it's just getting worse.' Patient will be turned every two hours." The nurse's notes provided no evidence the physician had been consulted. 6. Review of the nursing 24-Hour Report Sheet, dated 10/30/11, documented Resident #11 had a Stage II decubitis to her left buttock. The form provided no evidence the physician had been consulted. 7. Further review of Resident #11's clinical record revealed there was no evidence a physician's phone order had been written for treatment of [REDACTED]. There was also no evidence of a physician's progress note addressing the pressure ulcer or any other pressure ulcer. 8. During an interview on 11/9/11 at 3:48 p.m., Resident #11's PA stated she was informed of the pressure ulcer to Resident #11 buttocks on 11/8/11. She stated 11/8/11 was when she was first made aware of the skin issue with Resident #11. 9. Attempts were made to interview the agency nurse (RN "F"), but without success. Review of a statement, completed by RN "F" (Agency Nurse who found pressure ulcer), dated 11/9/11, documented a " female black CAN came to get her and said Resident #11 had something on her coccyx and her husband wanted a nurse to look at it. RN "F" stated she went to Resident #11's room and assessed the resident. RN "F" stated the husband repeated that the sore had been there and was getting worse. RN "F" stated she cleansed the sore with wound cleanser, covered it with something (couldn't remember what) and passed it on to the oncoming nurse." RN "F's" statement provided no evidence she had consulted with Resident #11's physician regarding the pressure ulcer. 10. Review of the Resident Census and Conditions of Residents (CMS Form 672), dated 11/7/11, documented a census of 52 residents.

Based on interviews and record reviews, it was determined the facility failed to ensure two allegations of abuse were reported to the Administrator (Abuse Coordinator) or his Designee, failed to thoroughly investigate the allegations, and failed to protect Resident #9 while the alleged perpetrator continued to work when: 1. 2 of 2 nurses (Charge Nurses LVN "A" and RN "B") failed to immediately report allegations of abuse made by Resident #9 on 2 separate occasions 8/11/11 and 8/15/11. These allegations of abuse were not reported to the Administrator or his Designee (DON). On August 15, 2011 an X-ray revealed a dislocation of the humerus. 2. The facility failed to thoroughly investigate Resident #9's allegations of abuse. 3. As a result of not doing a thorough investigation, the facility failed to protect Resident #9, and prevent the potential for abuse in the future. These failures led to the identification of an Immediate Jeopardy on 8/20/11. While the Immediate Jeopardy was removed on 8/22/11, the facility remained out of compliance at a level of potential but not more than minimal harm, with a scope identified as a pattern. The facility remained out of compliance due to all staff not being in-serviced on reporting, prevention, and protection from abuse The facility's failure to conduct thorough investigations of these incidents, resulted in Resident #9's physician or his representative to be consulted caused the resident to not receive treatment in a timely manner, which caused Resident #9 to experience unnecessary pain until the identification of a dislocated humerus was made. This failure placed the 30 residents who reside on Resident #9's hall, at risk for allegations of abuse not be immediately reported and investigated, which in the event of an incident may delay evaluation and treatment. The evidence is as follows: - Allegation of Abuse on 8/11/11 Review of Resident #9's clinical record, the face sheet documented an admission to the facility on [DATE], with the resident's current age being 92, with the following diagnoses, ischemic [MEDICAL CONDITIONS], diabetes, [MEDICAL CONDITION], dementia, chronic pain, hypertension, [MEDICAL CONDITION], and psoriasis. - Review of the annual MDS, dated [DATE], documented the resident had no long/short memory or decision making impairment. The resident required the extensive assist of 2 for transfer, personal hygiene, the extensive assist of 1 for dressing and was incontinent of bowel and bladder. The resident was wheelchair dependent. During an interview on 8/18/11 at 4:15 p.m., with Resident #9 in her room, she said, "Somebody came in and beat on me. They just came in and beat on my arm, it hurt." Review of Resident #9's nursing notes dated 8/15/11 at 3:15 p.m., and signed by Charge Nurse "A", documented the following: - (Late entry) On Thursday 8/11/11 resident complained of arm pain to the right arm. Asked Resident if she felt she needed an X-ray, Resident said, "No." Told resident that if she felt she needed one to let me know. Resident voiced understanding. Also on Friday 8/12/11 Resident complained of pain in her right arm again, once again asked if resident if she wanted an X-ray done or go to hospital and again refused. (Note no pain medication given) - (Late entry) 8/10/11 No bruises noted from fall (8/9/11). No complaints of pain/distress voiced/noted. - (Late entry) 8/11/11 No bruising noted related to fall. Voices no complaints of distress. Did complain of "Someone beating her up", this LVN asked resident who beat you, resident replied, "Nobody." - (Late entry) 8/12/11 Resident was moaning loud in room. Resident said, "I'm just hurting." During an interview on 8/20/11 at 2:10 p.m., with Charge Nurse "A", when the surveyor asked about the late entries on the chart, said she had forgotten to chart Resident #9 had told her someone had beat her up, so she charted the late entries. Charge Nurse "A" said she asked the resident who beat her up and she said nobody. Charge Nurse "A" admitted she did not tell anyone about the allegation, did not put it on the 24 hour shift to shift report, tell the oncoming nurse, do an investigation, or report it to the abuse coordinator. Charge Nurse "A" admitted she felt the statement "Somebody beat me up" was an allegation of abuse, and said, "I didn't think it was problem since she said nobody hurt her, I didn't know I had to report it." When asked who the abuse coordinator was for the facility, Charge Nurse "A" said, "I don't know." Charge Nurse "A" said admitted she did not tell the Administrator or his designee (DON) about the resident's allegation of abuse. Review of a hand written statement dated 8/20/11, and signed by Charge Nurse "A" documented the following: - 8/12/11 Was called to the resident's room by CMA "G", who said Resident #9 had said someone had beat her up. I went with CMA "G" to the resident's room, and asked the resident, "Who beat you up?" Resident #9 replied, "Nobody." At 10:00 p.m., I heard Resident #9 moaning loudly. I asked the resident what was wrong, and she said, "My arm hurts". I asked her again if she felt she needed to have an x-ray done and the resident said no. I did not tell the Administrator or the DON about the allegation of abuse. During an interview on 8/19/11 at 5:50 p.m., with CMA "G" she said she was in the resident's room on the evening of 8/11/11. The resident told her somebody had beat her up. CMA "G" said she told Charge Nurse "A". She said Charge Nurse "A" went to the resident's room and asked her who had beat her up, and the resident said "Nobody" CMA"G" said she did not tell the Administrator (Abuse Coordinator) or the DON of the allegation of abuse. During an interview on 8/19/11 at 3:50 p.m., the Administrator said he had not received any information about Resident #9 saying someone had beat her up from Charge Nurse "A" or the DON. The Administrator said he was the Abuse Coordinator for the facility, and will designate the DON at times to conduct the investigations. The Administrator admitted he did not do an investigation. During an interview on 8/19/11 at 1:20 p.m., the DON said she had not received any information about the allegation of abuse made by Resident #9. The DON said Charge Nurse "A" did not tell me about the incident, and she had not listed the allegation of abuse on the 24 hour shift report. The DON said she knew she had to do an investigation, but had failed to do so. Review of the typed statement, dated 8/15/11, and signed by the DON documented the following: - I interviewed Charge Nurse "A" on 8/15/11 about Resident #9 and her allegation of abuse. Resident #9 had told Charge Nurse "A" she felt like she had been beaten. Charge Nurse "A" asked the resident if anyone harmed her and she stated no. Charge Nurse "A" said she did not tell anyone about the allegation of abuse. I did an in-service with Charge Nurse "A" on 8/15/11 on documentation, the 24 hour report and the importance of notifying the Administrator immediately of abuse allegations, and the physician with any change of condition. The DON admitted she did not investigate the resident's allegation of abuse. During an interview on 8/18/11 at 4:45 p.m., with the ADON, she said she had not been told Resident #9 had made an allegation of abuse, and did not do an investigation. - Allegation of Abuse made on 8/15/11 During an interview on 8/19/11 at 1:45 p.m., with CNA "E", she said she moved Resident #9's arm the morning of 8/15/11, and the resident yelled out in pain. When she asked the resident what was wrong, the resident told her a black lady had pulled on her arm and hurt her. CNA "E" admitted she did not tell the Administrator, DON or ADON about the allegation. CNA "E" said, " I told the charge nurse, I assumed she would take care of it." Review of the hand written statement dated 8/19/11, and signed by CNA "E" documented the following: - I walked into patient room, Resident #9 to change her brief. Resident #9 had complained about her right arm. I asked the resident what happened to her arm. Resident #9 told me that a big black lady came in and pulled on her arm. So I went and reported it to my charge nurse, RN "B". We both went into the resident's room, Charge Nurse RN "B" checked the arm and she (Resident #9) yelled out in pain. I did not discuss the allegation with the Administrator, ADON or DON. During an interview on 8/19/11 at 4:30 p.m., with RN "B", she said CNA "E" came and told her Resident #9 said a black girl had pulled on her arm and hurt her. RN "B" said she went to the resident's room and asked her who had hurt her. RN "B" said Resident #9 told her nobody had hurt her. RN "B" said she told the ADON on 8/15/11 after she left Resident #9's room about the resident's allegation of abuse. RN "B" said she also told the DON later in the morning on 8/15/11 about the allegation of abuse. RN "B" said she also wrote out a communication form and slid it under the SW's door. Charge Nurse RN "B" said, "Without a doubt I told the ADON and DON the resident had said some black lady pulled on her arm." RN "B" said an investigation was not done, and she doesn't know why. RN "B" said she went back to the ADON and asked, "Who do you think hurt Resident #9's arm." She said the ADON said the resident always complained about her arm, and had pain all the time. RN "B" said she spoke to the DON, and she said you know how the she rolls over, and the DON even moved her shoulders like the resident does, and that had probably caused her pain. RN "B" admitted she had not told the Administrator about the resident's allegation of abuse. Charge Nurse RN "B" identified the Administrator as the Abuse Coordinator. Review of the written statement, undated, signed by RN "B" documented the following: - CNA "E" came to me on 8/15/11 and said Resident #9 told her that her arm was pulled over the weekend, and a big black girl hurt it. I went in to assess the right arm. I asked her did she know who hurt her and she said no one hurt her. I went to the ADON's office and told her about what CMA "E" had said. I also did tell the DON when she came in that morning, I told her I called the PA, the arm was hurt, and told her the resident's allegation of abuse. I did make a concern on the communication form, not the grievance form, and slid it under the door of the SW. I asked the ADON if she thought someone had hurt the resident's arm, and the ADON said, the resident has many pains and felt that it could have come from a fall a few weeks before. During an interview on 8/18/11 at 4:45 p.m., with the ADON, she said, on 8/15/11, RN "B" came and told her Resident #9 complained of right arm pain. There was no redness or swelling, but when you touched her right arm she said "OOW", so something was wrong. The ADON thought the pain was probably from the fall on August 9th. Review of a written statement, dated 8/19/11, and signed by the ADON documented the following: - On Monday (August) 15, 2011, RN"B" notified me around 12:00 or 1:00 (p.m.) of x-ray results Resident #9 had a possible fracture to her right arm and needed okay for non emergency transport to the hospital. I asked what happened, she (RN "B") stated Resident #9 complained of right arm pain earlier. Also stated she (Resident #9) wasn't hurt by anyone. I went and spoke with her (Resident #9), she also stated she had no problems and no one hurt her. I never heard or was told about anyone hurting Resident #9. During an interview on 8/19/11 at 6:30 p.m., with the SW she said, "Resident #9 told me that her arm hurt. The SW said, "I didn't see anything wrong so I didn't put it on a grievance. The SW denied she received any type of documentation concerning the resident's injury from RN "B". The SW conducted an inventory of the notifications she had received, with the surveyor present, and no documentation about the resident's injury was found. Review of a written statement dated 8/19/11 and signed by the SW documented the following: - Went to my office on 8/19/11 at 6:15 p.m., and looked for a communication form regarding the resident, saying someone had pulled on her arm, but I did not have one. A CNA on the 2 p.m. to 10 p.m. shift stopped by my office and asked me to go look in on Resident #9. She (CNA) stated the resident was complaining of her arm hurting, I went into her room and asked her what happened. She (Resident #9) told me her arm hurt, so I looked at it. She (Resident #9) flinched when I touched her arm, so I went and got the nurse. We went and looked at it again, and again I asked her what happened and she said it hurt. Review of Resident #9's Nurses Notes dated 8/15/11 at 7:40 a.m., and signed by Charge Nurse RN "B" documented the following: - CNA came, Resident complains of right arm pain. Says "It just hurts. Says "No one hurt it, but it hurts." - 7:45 a.m., Left message for the PA concerning right arm pain. - 11:00 p.m., Ok' d for x-ray. - 1:55 p.m., X-ray back, possible dislocation. - 2:20 p.m., Paramedics called for non emergency transport. - 2:45 p.m., Spoke with resident, states no one hurt her, it just feels like it. (This entry was made by the ADON). - 4:00 p.m., Paperwork ready and sent to the hospital. Review of the Patient/Resident Incident/Accident Worksheet, dated 8/15/11 at 7:40 a.m., documented the following: - Says right arm hurts. "No one hurt it, but it hurts so bad." (Resident #9) Yelling out when right arm moved. X-ray to be done. Review of the physician's orders [REDACTED]. - (X-ray) Right forearm, right Humerus, for increased pain for 2 days Review of the Radiology Report, dated 8/15/11 at 1:03 p.m., documented the following: - The right humerus demonstrates a dislocation of the humerus with medial displacement of the shaft. (Note X-ray done at facility) Review of the Hospital Record, dated 8/15/11, documented the following: - 4:18 p.m., Nurse's Notes, Brought from nursing home where she reportedly fell sometime this weekend and broke her right humerus. - 8:49 a.m., Radiology report, Right Shoulder 1 view: Single view of the right shoulder demonstrates an anterior dislocation of the shoulder joint. - 8:49 a.m., Radiology report, Humerus: There is no [MEDICAL CONDITION] shaft. There is an anterior dislocation of the shoulder joint. - 8:52 a.m., Radiology report, Post Reduction: Two views of the shoulder were obtained. These demonstrate successful reduction of the anterior dislocation. The findings are consistent with a rotator cuff tear in the appropriate clinical setting. - (no time listed) Progress Notes, Shoulder dislocation reduction. Under conscious sedation (administration of medication to cause sedation, but patient is easily arouseable) right shoulder reduced using axillary tension and external rotation with easy reduction. Repeat x-ray shows successful reduction. During an interview on 8/19/11 at 1:00 p.m., with the ADON, when asked if there had been an African American woman on duty the night of 8/14/11, she identified CNA "C" as the only African American on duty on Resident #9's hall. During an interview on 8/19/11 at 2:00 p.m., with CNA "C" (alleged perpetrator), she said she worked on the 10 p.m. to 6:00 a.m., shift on 8/14/11. CNA "C" said she doesn't remember Resident #9 complaining of pain on the night shift of the 14th. During a follow up interview on 8/19/11 at 4:35 p.m., with CNA "C", she said she had someone with her at all times when she entered Resident #9's room on 8/14/11. CNA "C" said the resident would grab onto the side rails and help roll herself over. CNA "C" said at no time did she pull on the resident's arm. Review of a written statement dated 8/19/11, and signed by CNA "C" documented the following: - Sunday (8/14/11) on the 10 p.m. to 6:00 a.m. shift, myself and CNA "D" worked. We did rounds, when we got to Resident #9 to change her, she was telling me about some people that she didn't want up here because the man was abusive. Review of the facility submitted form titled, Employee Monthly Time Report, dated 9/1/11, documented CNA "C" worked the 10 p.m. to 6:00 a.m. shift on the nights of 8/8/11, 8/9/11, 8/10/11,8/12/11, 8/14/11, 8/15/11, 8/16/11,8/17/11 and 8/18/11. During an interview on 8/19/11 at 3:05 p.m., with the DON, she said RN "B" had told her Resident #9's arm was hurting, and they were waiting for an x-ray report. The DON said she was never told someone had pulled on the resident's arm. The DON said she had not been told about Resident #9's allegation of abuse. The DON admitted she had not done an investigation concerning the allegation until 8/19/11. Review of a typed statement, dated 8/15/11, and signed by the DON documented the following: - On Monday August 15th, 2011 RN"B" reported Resident #9 complained of severe pain to her right arm. Order received for x-ray and when results were received there was an order to send her (Resident #9) to a local hospital for evaluation of dislocation to arm. RN "B" was interviewed and she said this was the first day that Resident #9 had complained to her (RN "B") of pain. Review of a hand written statement, dated 8/19/11, and signed by the DON documented the following: - On Monday August 15th, I came in and walked through the nurse's station, around 7:30 a.m., and RN "B" stopped me after I asked if they were doing okay on the unit and she told me that Resident #9 was complaining of right arm pain. She (RN "B") said she had called the PA to possibly get an x-ray and RN "B" would let me know when the results were in. During an interview on 8/19/11 at 3:10 p.m., with the Administrator, he said he became aware of the incident when the facility received the x-ray report of the dislocated humerus. The Administrator said he was never told about the allegations the resident had made. Review of a typed statement, dated 8/19/11, and signed by the Administrator, documented the following: - On August 15, 2011 at approximately 1:30 p.m., this Administrator was notified by the Director of Nurses of a possible fracture to Resident #9's right arm. Upon review of the resident's x-ray exam, the report stated possible dislocation of the humerus. The Administrator initiated an investigation on 8/15/11 regarding the cause of the dislocation. The investigation was focused on the 8/9/11 fall. At no time was it reported to this Administrator that the resident made an allegation of abuse/neglect concerning a black female pulling her arm. Review of the facility submitted Policy and Procedure titled, Abuse, Neglect, and Misappropriation Of Property, revised 2/2008 documented the following: Policy: The facility's leadership prohibits neglect, mental or physical abuse, including involuntary seclusion and misappropriation of a resident's property and/or funds. The facility's leadership will conduct a prompt investigation of any allegation received of suspected abuse/neglect. The facility leadership will implement appropriate and necessary guidelines which prohibit the mistreatment, neglect and abuse of the patient/resident. - All alleged violations concerning abuse, neglect are misappropriation of property are reported verbally immediately to the Administrator/Designee. - The facility maintains that all allegations of abuse, neglect, misappropriation of property etc. are thoroughly investigated and appropriate actions are taken. - Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions. The facility conducts an internal investigation and reports the results to enforcement agencies with in 5 working days or as prescribed by State law. - In the event an employee is accused of abuse/neglect, that employee will be suspended during the investigation process. If the allegations are founded, the suspension is without pay and appropriate disciplinary actions are taken. - Training: All new and present employees receive continuous education, training and reinforcement that identifies all aspects of abuse prohibition, to include the prompt reporting of allegations without fear of reprisal, identification of persons who could fall victim to alleged or suspected abuse. - Protection: During the investigation, the facility protects the resident, as appropriate, including but not limited to removal of the alleged abuser for the resident care setting. - Prevention: Handouts which include information on how to and to whom concerns are reported to without fear of retribution is distributed at admission, displayed in a prominent place in the facility, and during resident council meeting. Adequate supervision of staff is maintained in order to identify and prevent inappropriate behaviors such as the use of derogatory/harassing language, rough handling, and ignoring the residents needs - Ongoing assessment, care planning and monitoring of those residents with special needs that may lead to neglect. - Identification: Staff members identify and assess suspected alleged reports of abuse or neglect, focusing on objective and observable evidence, such as suspicious bruising, witness reports regarding unusual occurrences, patterns and trends of potential abuse or neglect. The Administrator, Corporate Vice President, and Corporate Nurse were notified of the identification of an Immediate Jeopardy on 8/20/11. Plan of Action: Resident #9's care plan was updated and a new MDS change in condition was done on 8/20/11. The following employees have been suspended pending the outcome of the investigation **From the description of the alleged individual "jerking" the resident's arm, C.N.A. "C" was suspended pending investigation on 8-19-11 and later found to be unsubstantiated, therefore the employee will be permitted to return to work with re-education of the facility Abuse and Abuse Prohibition policy. ** SW was suspended pending investigation related to potentially having knowledge of Resident #9's complaints and allegations. After investigation, SW will be permitted to return to work with re-education and written counseling 8-21-11. **ADON was also suspended pending investigation on 8-19-11 related to possibly not taking appropriate action when issues of potential abuse were reported. Upon further investigation, a final determination concluded the ADON did not know anything about the alleged abuse and that her documentation in the chart was reflective of what the resident told her and she had no reason to believe it was anything different. The ADON will be reinstated and receive re-education regarding abuse and neglect policy and procedures. **Based on findings and lack of completing a thorough investigation, the DON was suspended pending investigation of the alleged events. The suspension is effective 8-19-11. Based on investigation, it has been determined the DON did potentially have knowledge of the allegation of abuse and failed to investigate as delegated by the Administrator. After investigation of the issue, this employee will be terminated on 8-22-11. **In review of the record and interviews with RN "B", it is determined that RN "B" failed to follow policy, it is the intent that all staff would notify the Abuse Investigative Officer of any alleged abuse. Based on the documented verbal exchange and documentation, RN "B" was suspended pending investigation effective 8-19-11 and which will lead to termination of her employment. **In review of the record and interviews with LVN "A", it is determined that LVN "A" failed to follow policy, it is the intent that all staff would notify the Abuse Investigative Officer of any alleged abuse. Based on the documented verbal exchange and documentation, LVN "A" was suspended pending investigation effective 8-19-11 and which will lead to termination of her employment. Re-education began on 8-19-11 and included physical and emotional abuse, neglect and misappropriation. The education also included reporting timelines and completing a thorough investigation. Licensed staff was educated on notification of family and physician related to any type of abuse beginning 8-20-11. All shifts including routine and those on 4-2 rotation will be covered to assure that all staff have been re-in-serviced prior to returning to work. The Administrator will be re-educated on abuse reporting and completing a thorough investigation 8-20-11 by the Regional Vice President of Operations. A retrospective audit, including June 2011 forward will be conducted by the Clinical Services Director, which will include the abuse log which includes resident name, date reported, date of incident, type of allegation of abuse, family notified, physician notified, initial reporting, 5 day reporting, care plan reviewed, substantiated or not, date resolved and comments. To be completed by 8-22-11. Residents will be assessed for any further allegations of abuse and documented in the clinical record. Non interviewable residents will be assessed for signs and symptoms of abuse and documentation of the assessment to be placed in the clinical record. To be done by facility Social Worker assisted by Clinical Services Director and Administrator. Incident reports will be reviewed daily for possible allegation of abuse or injuries of unknown origin. Any area of concern will immediately be opened as an investigation and reported to the state by regulation. The facility will initiate an investigation and suspend any possible employees related to the incident pending investigation. The Administrator will be responsible for monitoring this process. All allegation potential or actual will be reported to the Clinical Services Director. The facility will recruit and hire a Risk Management Nurse. Included in his/her duties will be timely and thorough investigations of all allegations of abuse, neglect or misappropriation. When hired the Risk Management Nurse will function as the Abuse Coordinator. The Risk Management Nurse will be responsible for facility wide education for all current employees and new employees related to abuse, neglect and misappropriation. This nurse will also review all incident/accidents for possible need for further investigation. The facility will do a retrospective review of the grievance logs back to June and July. Facility residents with allegations of abuse/neglect will be reported timely to the Administrator/Director of Nursing and Social Services. Allegations of abuse will be investigated as per policy and reported timely to appropriate agencies per the regulation. Facility staff and agency staff were re-educated on abuse, neglect and misappropriation. No staff will be permitted to work until they completed the education. Audits will be completed weekly and presented to the performance improvement committee monthly. Any areas of concern will be corrected at the time of discovery. The Administrator will monitor this practice on an ongoing basis. Based on interviews with facility staff, the facility had inserviced staff on facility policy on reporting, thorough investigating allegations of abuse and to whom to report such allegations. The facility had also inserviced staff on protecting residents. While the Immediate Jeopardy was removed on 8/22/11, the facility remained out of compliance at a level of potential for no more than minimal harm, with a scope identified as a pattern. The facility remained out of compliance due to not all of the staff had been in-serviced regarding the reporting of all allegations and thoroughly investigate all allegations of abuse. Review of the facility submitted form, untitled, dated 8/17/11, documented a census of 30 on Resident #9's hall.

Based on interviews and record reviews, it was determined the facility failed to ensure their written Policy and Procedures were followed when two allegations of abuse were not thoroughly investigated when reports of allegations were not made to the Administrator (Abuse Coordinator), and to protect Resident #9 while the alleged perpetrator continued to work, and to prevent any further potential abuse when: 1. 2 of 2 nurses (Charge Nurses LVN "A" and RN "B") failed to immediately report allegations of abuse made by Resident #9 on 2 separate occasions 8/11/11 and 8/15/11. These allegations of abuse were not reported to the Administrator or his Designee (DON). On August 15, 2011 an X-ray revealed a dislocation of the humerus. 2. The facility failed to thoroughly investigate Resident #9's allegations of abuse. 3. As a result of not doing a thorough investigation, the facility failed to protect Resident #9, and prevent the potential for abuse in the future. These failures led to the identification of an Immediate Jeopardy on 8/20/11. While the Immediate Jeopardy was removed on 8/22/11, the facility remained out of compliance at a level of potential but not more than minimal harm, with a scope identified as a pattern. The facility remained out of compliance due to all staff not being in-serviced on reporting, prevention, and protection from abuse The facility's failure to conduct thorough investigations of these incidents, resulted in Resident #9's physician or his representative to be consulted caused the resident to not receive treatment in a timely manner, which caused Resident #9 to experience unnecessary pain until the identification of a dislocated humerus was made. This failure placed the 30 residents who reside on Resident #9's hall, at risk for allegations of abuse not be immediately reported and investigated, which in the event of an incident may delay evaluation and treatment. The evidence is as follows: Review of the facility submitted Policy and Procedure titled, Abuse, Neglect, and Misappropriation Of Property, revised 2/2008 documented the following: Policy: The facility's leadership prohibits neglect, mental or physical abuse, including involuntary seclusion and misappropriation of a resident's property and/or funds. The facility's leadership will conduct a prompt investigation of any allegation received of suspected abuse/neglect. The facility leadership will implement appropriate and necessary guidelines which prohibit the mistreatment, neglect and abuse of the patient/resident. - All alleged violations concerning abuse, neglect are misappropriation of property are reported verbally immediately to the Administrator/Designee. - The facility maintains that all allegations of abuse, neglect, misappropriation of property etc. are thoroughly investigated and appropriate actions are taken. - Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions. The facility conducts an internal investigation and reports the results to enforcement agencies with in 5 working days or as prescribed by State law. - In the event an employee is accused of abuse/neglect, that employee will be suspended during the investigation process. If the allegations are founded, the suspension is without pay and appropriate disciplinary actions are taken. - Training: All new and present employees receive continuous education, training and reinforcement that identifies all aspects of abuse prohibition, to include the prompt reporting of allegations without fear of reprisal, identification of persons who could fall victim to alleged or suspected abuse. - Protection: During the investigation, the facility protects the resident, as appropriate, including but not limited to removal of the alleged abuser for the resident care setting. - Prevention: Handouts which include information on how to and to whom concerns are reported to without fear of retribution is distributed at admission, displayed in a prominent place in the facility, and during resident council meeting. Adequate supervision of staff is maintained in order to identify and prevent inappropriate behaviors such as the use of derogatory/harassing language, rough handling, and ignoring the residents needs - Ongoing assessment, care planning and monitoring of those residents with special needs that may lead to neglect. - Identification: Staff members identify and assess suspected alleged reports of abuse or neglect, focusing on objective and observable evidence, such as suspicious bruising, witness reports regarding unusual occurrences, patterns or trends of potential abuse or neglect. - Allegation of Abuse on 8/11/11 Review of Resident #9's clinical record, the face sheet documented an admission to the facility on [DATE], with the resident's current age being 92, with the following diagnoses, ischemic [MEDICAL CONDITIONS], diabetes, [MEDICAL CONDITION], dementia, chronic pain, hypertension, [MEDICAL CONDITION], and psoriasis. - Review of the annual MDS, dated [DATE], documented the resident had no long/short memory or decision making impairment. The resident required the extensive assist of 2 for transfer, personal hygiene, the extensive assist of 1 for dressing and was incontinent of bowel and bladder. The resident was wheelchair dependent. During an interview on 8/18/11 at 4:15 p.m., with Resident #9 in her room, she said, "Somebody came in and beat on me. They just came in and beat on my arm, it hurt." Review of Resident #9's nursing notes dated 8/15/11 at 3:15 p.m., and signed by Charge Nurse "A", documented the following: - (Late entry) On Thursday 8/11/11 resident complained of arm pain to the right arm. Asked Resident if she felt she needed an X-ray, Resident said, "No." Told resident that if she felt she needed one to let me know. Resident voiced understanding. Also on Friday 8/12/11 Resident complained of pain in her right arm again, once again asked if resident if she wanted an X-ray done or go to hospital and again refused. (Note no pain medication given) - (Late entry) 8/10/11 No bruises noted from fall (8/9/11). No complaints of pain/distress voiced/noted. - (Late entry) 8/11/11 No bruising noted related to fall. Voices no complaints of distress. Did complain of "Someone beating her up", this LVN asked resident who beat you, resident replied, "Nobody." - (Late entry) 8/12/11 Resident was moaning loud in room. Resident said, "I'm just hurting." During an interview on 8/20/11 at 2:10 p.m., with Charge Nurse "A" , when the surveyor asked about the late entries on the chart, said she had forgotten to chart the resident had told her someone had beat her up, so she charted the late entries. LVN "A" said she asked the resident who beat her up and she said nobody. Charge Nurse "A" admitted she did not tell anyone about the allegation, did not put it on the 24 hour shift to shift report, tell the oncoming nurse, do an investigation, or report it to the abuse coordinator. Charge Nurse "A" admitted she felt the statement "Somebody beat me up" was an allegation of abuse, and said, "I didn't think it was problem since she said nobody hurt her, I didn't know I had to report it." When asked who the abuse coordinator was for the facility, Charge Nurse "A" said, "I don't know." Charge Nurse "A" said admitted she did not tell the Administrator or his designee (DON) about the resident's allegation of abuse. Review of a hand written statement dated 8/20/11, and signed by Charge Nurse "A" documented the following: - 8/12/11 Was called to the resident's room by CMA "G", who said Resident #9 had said someone had beat her up. I went with CMA "G" to the resident's room, and asked the resident, "Who beat you up?" Resident #9 replied, "Nobody." At 10:00 p.m., I heard Resident #9 moaning loudly. I asked the resident what was wrong, and she said, "My arm hurts". I asked her again if she felt she needed to have an x-ray done and the resident said no. I did not tell the Administrator or the DON about the allegation of abuse. During an interview on 8/19/11 at 5:50 p.m., with CMA "G" she said she was in the resident's room on the evening of 8/11/11. The resident told her somebody had beat her up. CMA "G" said she told Charge Nurse "A". She said Charge Nurse "A" went to the resident's room and asked her who had beat her up, and the resident said "Nobody" CMA"G" said she did not tell the Administrator (Abuse Coordinator) or the DON of the allegation of abuse. During an interview on 8/19/11 at 3:50 p.m., the Administrator said he had not received any information about Resident #9 saying someone had beat her up from Charge Nurse "A" or the DON. The Administrator said he was the Abuse Coordinator for the facility, and will designate the DON at times to conduct the investigations. The Administrator admitted he did not do an investigation. During an interview on 8/19/11 at 1:20 p.m., the DON said she had not received any information about the allegation of abuse made by Resident #9. The DON said Charge Nurse LVN "A" did not tell me about the incident, and she had not listed the allegation of abuse on the 24 hour shift report. The DON said she knew she had to do an investigation, but had failed to do so. Review of the typed statement, dated 8/15/11, and signed by the DON documented the following: - I interviewed Charge Nurse "A" on 8/15/11 about Resident #9 and her allegation of abuse. Resident #9 had told Charge Nurse "A"she felt like she had been beaten. Charge Nurse "A" asked the resident if anyone harmed her and she stated no. Charge Nurse "A" said she did not tell anyone about the allegation of abuse. I did an in-service with Charge Nurse "A" on 8/15/11 on documentation, the 24 hour report and the importance of notifying the Administrator immediately of abuse allegations, and the physician with any change of condition. The DON admitted she did not investigate the resident's allegation of abuse. During an interview on 8/18/11 at 4:45 p.m., with the ADON, she said she had not been told Resident #9 had made an allegation of abuse, and did not do an investigation. - Allegation of Abuse made on 8/15/11 During an interview on 8/19/11 at 1:45 p.m., with CNA "E", she said she moved Resident #9's arm the morning of 8/15/11, and the resident yelled out in pain. When she asked the resident what was wrong, the resident told her a black lady had pulled on her arm and hurt her. CNA "E" admitted she did not tell the Administrator, DON or ADON about the allegation. CNA "E" said, " I told the charge nurse, I assumed she would take care of it." Review of the hand written statement dated 8/19/11, and signed by CNA "E" documented the following: - I walked into patient room, Resident #9 to change her brief. Resident #9 had complained about her right arm. I asked the resident what happened to her arm. Resident #9 told me that a big black lady came in and pulled on her arm. So I went and reported it to my charge nurse, RN "B". We both went into the resident's room, Charge Nurse RN "B" checked the arm and she (Resident #9) yelled out in pain. I did not discuss the allegation with the Administrator, ADON or DON. During an interview on 8/19/11 at 4:30 p.m., with RN "B", she said CNA "E" came and told her Resident #9 said a black girl had pulled on her arm and hurt her. RN "B" said she went to the resident's room and asked her who had hurt her. RN "B" said Resident #9 told her nobody had hurt her. RN "B" said she told the ADON on 8/15/11 after she left Resident #9's room about the resident's allegation of abuse. RN "B" said she also told the DON later in the morning on 8/15/11 about the allegation of abuse. RN "B" said she also wrote out a communication form and slid it under the SW's door. Charge Nurse RN "B" said, "Without a doubt I told the ADON and DON the resident had said some black lady pulled on her arm." RN "B" said an investigation was not done, and she doesn't know why. RN "B" said she went back to the ADON and asked, "Who do you think hurt Resident #9's arm." She said the ADON said the resident always complained about her arm, and had pain all the time.. RN "B" said she spoke to the DON, and she said you know how the she rolls over, and the DON even moved her shoulders like the resident does, and that had probably caused her pain. RN "B" admitted she had not told the Administrator about the resident's allegation of abuse. Charge Nurse RN "B" identified the Administrator as the Abuse Coordinator. Review of the written statement, undated, signed by RN "B" documented the following: - CNA "E" came to me on 8/15/11 and said Resident #9 told her that her arm was pulled over the weekend, and a big black girl hurt it. I went in to assess the right arm. I asked her did she know who hurt her and she said no one hurt her. I went to the ADON's office and told her about what CMA "E" had said. I also did tell the DON when she came in that morning, I told her I called the PA, the arm was hurt, and told her the resident's allegation of abuse. I did make a concern on the communication form, not the grievance form, and slid it under the door of the SW. I asked the ADON if she thought someone had hurt the resident's arm, and the ADON said, the resident has many pains and felt that it could have come from a fall a few weeks before. During an interview on 8/18/11 at 4:45 p.m., with the ADON, she said, on 8/15/11, RN "B" came and told her Resident #9 complained of right arm pain. There was no redness or swelling, but when you touched her right arm she said "OOW", so something was wrong. The ADON thought the pain was probably from the fall on August 9th. Review of a written statement, dated 8/19/11, and signed by the ADON documented the following: - On Monday (August) 15, 2011, RN"B" notified me around 12:00 or 1:00 (p.m.) of x-ray results Resident #9 had a possible fracture to her right arm and needed okay for non emergency transport to the hospital. I asked what happened, she (RN "B") stated Resident #9 complained of right arm pain earlier. Also stated she (Resident #9) wasn't hurt by anyone. I went and spoke with her (Resident #9), she also stated she had no problems and no one hurt her. I never heard or was told about anyone hurting Resident #9. During an interview on 8/19/11 at 6:30 p.m., with the SW she said, "Resident #9 told me that her arm hurt. The SW said, "I didn't see anything wrong so I didn't put it on a grievance. The SW denied she received any type of documentation concerning the resident's injury from RN "B". The SW conducted an inventory of the notifications she had received, with the surveyor present, and no documentation about the resident's injury was found. Review of a written statement dated 8/19/11 and signed by the SW documented the following: - Went to my office on 8/19/11 at 6:15 p.m., and looked for a communication form regarding the resident, saying someone had pulled on her arm, but I did not have one. A CNA on the 2 p.m. to 10 p.m. shift stopped by my office and asked me to go look in on Resident #9. She (CNA) stated the resident was complaining of her arm hurting, I went into her room and asked her what happened. She (Resident #9) told me her arm hurt, so I looked at it. She (Resident #9) flinched when I touched her arm, so I went and got the nurse. We went and looked at it again, and again I asked her what happened and she said it hurt. Review of Resident #9's Nurses Notes dated 8/15/11 at 7:40 a.m., and signed by Charge Nurse RN "B" documented the following: - CNA came, Resident complains of right arm pain. Says "It just hurts. Says "No one hurt it, but it hurts." - 7:45 a.m., Left message for the PA concerning right arm pain. - 11:00 p.m., Ok' d for x-ray. - 1:55 p.m., X-ray back, possible dislocation. - 2:20 p.m., Paramedics called for non emergency transport. - 2:45 p.m., Spoke with resident, states no one hurt her, it just feels like it. (This entry was made by the ADON). - 4:00 p.m., Paperwork ready and sent to the hospital. Review of the Patient/Resident Incident/Accident Worksheet, dated 8/15/11 at 7:40 a.m., documented the following: - Says right arm hurts. "No one hurt it, but it hurts so bad." (Resident #9) Yelling out when right arm moved. X-ray to be done. Review of the physician's orders [REDACTED]. - (X-ray) Right forearm, right Humerus, for increased pain for 2 days Review of the Radiology Report, dated 8/15/11 at 1:03 p.m., documented the following: - The right humerus demonstrates a dislocation of the humerus with medial displacement of the shaft. (Note X-ray done at facility) Review of the Hospital Record, dated 8/15/11, documented the following: - 4:18 p.m., Nurse's Notes, Brought from nursing home where she reportedly fell sometime this weekend and broke her right humerus. - 8:49 a.m., Radiology report, Right Shoulder 1 view: Single view of the right shoulder demonstrates an anterior dislocation of the shoulder joint. - 8:49 a.m., Radiology report, Humerus: There is no [MEDICAL CONDITION] shaft. There is an anterior dislocation of the shoulder joint. - 8:52 a.m., Radiology report, Post Reduction: Two views of the shoulder were obtained. These demonstrate successful reduction of the anterior dislocation. The findings are consistent with a rotator cuff tear in the appropriate clinical setting. - (no time listed) Progress Notes, Shoulder dislocation reduction. Under conscious sedation (administration of medication to cause sedation, but patient is easily arouseable) right shoulder reduced using axillary tension and external rotation with easy reduction. Repeat x-ray shows successful reduction. During an interview on 8/19/11 at 1:00 p.m., with the ADON, when asked if there had been an African American woman on duty the night of 8/14/11, she identified CNA "C" as the only African American on duty on Resident #9's hall. During an interview on 8/19/11 at 2:00 p.m., with CNA "C" (alleged perpetrator), she said she worked on the 10 p.m. to 6:00 a.m., shift on 8/14/11. CNA "C" said she doesn't remember Resident #9 complaining of pain on the night shift of the 14th. During a follow up interview on 8/19/11 at 4:35 p.m., with CNA "C", she said she had someone with her at all times when she entered Resident #9's room on 8/14/11. CNA "C" said the resident would grab onto the side rails and help roll herself over. CNA "C" said at no time did she pull on the resident's arm. Review of a written statement dated 8/19/11, and signed by CNA "C" documented the following: - Sunday (8/14/11) on the 10 p.m. to 6:00 a.m. shift, myself and CNA "D" worked. We did rounds, when we got to Resident #9 to change her, she was telling me about some people that she didn't want up here because the man was abusive. Review of the facility submitted form titled, Employee Monthly Time Report, dated 9/1/11, documented CNA "C" worked the 10 p.m. to 6:00 a.m. shift on the nights of 8/8/11, 8/9/11, 8/10/11,8/12/11, 8/14/11, 8/15/11, 8/16/11,8/17/11 and 8/18/11. During an interview on 8/19/11 at 3:05 p.m., with the DON, she said RN "B" had told her Resident #9's arm was hurting, and they were waiting for an x-ray report. The DON said she was never told someone had pulled on the resident's arm. The DON said she had not been told about Resident #9's allegation of abuse. The DON admitted she had not done an investigation concerning the allegation until 8/19/11. Review of a typed statement, dated 8/15/11, and signed by the DON documented the following: - On Monday August 15th, 2011 RN"B" reported Resident #9 complained of severe pain to her right arm. Order received for x-ray and when results were received there was an order to send her (Resident #9) to a local hospital for evaluation of dislocation to arm. RN "B" was interviewed and she said this was the first day that Resident #9 had complained to her (RN "B") of pain. Review of a hand written statement, dated 8/19/11, and signed by the DON documented the following: - On Monday August 15th, I came in and walked through the nurse's station, around 7:30 a.m., and RN "B" stopped me after I asked if they were doing okay on the unit and she told me that Resident #9 was complaining of right arm pain. She (RN "B") said she had called the PA to possibly get an x-ray and RN "B" would let me know when the results were in. During an interview on 8/19/11 at 3:10 p.m., with the Administrator, he said he became aware of the incident when the facility received the x-ray report of the dislocated humerus. The Administrator said he was never told about the allegations the resident had made. Review of a typed statement, dated 8/19/11, and signed by the Administrator, documented the following: - On August 15, 2011 at approximately 1:30 p.m., this Administrator was notified by the Director of Nurses of a possible fracture to Resident #9's right arm. Upon review of the resident's x-ray exam, the report stated possible dislocation of the humerus. The Administrator initiated an investigation on 8/15/11 regarding the cause of the dislocation. The investigation was focused on the 8/9/11 fall. At no time was it reported to this Administrator that the resident made an allegation of abuse/neglect concerning a black female pulling her arm. The Administrator, Corporate Vice President, and Corporate Nurse were notified of the identification of an Immediate Jeopardy on 8/20/11. Plan of Action: Resident #9's care plan was updated and a new MDS change in condition was done on 8/20/11. The following employees have been suspended pending the outcome of the investigation **From the description of the alleged individual "jerking" the resident's arm, C.N.A. "C" was suspended pending investigation on 8-19-11 and later found to be unsubstantiated, therefore the employee will be permitted to return to work with re-education of the facility Abuse and Abuse Prohibition policy. ** SW was suspended pending investigation related to potentially having knowledge of Resident #9's complaints and allegations. After investigation, SW will be permitted to return to work with re-education and written counseling 8-21-11. **ADON was also suspended pending investigation on 8-19-11 related to possibly not taking appropriate action when issues of potential abuse were reported. Upon further investigation, a final determination concluded the ADON did not know anything about the alleged abuse and that her documentation in the chart was reflective of what the resident told her and she had no reason to believe it was anything different. The ADON will be reinstated and receive re-education regarding abuse and neglect policy and procedures. **Based on findings and lack of completing a thorough investigation, the DON was suspended pending investigation of the alleged events. The suspension is effective 8-19-11. Based on investigation, it has been determined the DON did potentially have knowledge of the allegation of abuse and failed to investigate as delegated by the Administrator. After investigation of the issue, this employee will be terminated on 8-22-11. **In review of the record and interviews with RN "B", it is determined that RN "B" failed to follow policy, it is the intent that all staff would notify the Abuse Investigative Officer of any alleged abuse. Based on the documented verbal exchange and documentation, RN "B" was suspended pending investigation effective 8-19-11 and which will lead to termination of her employment. **In review of the record and interviews with LVN "A", it is determined that LVN "A" failed to follow policy, it is the intent that all staff would notify the Abuse Investigative Officer of any alleged abuse. Based on the documented verbal exchange and documentation, LVN "A" was suspended pending investigation effective 8-19-11 and which will lead to termination of her employment. Re-education began on 8-19-11 and included physical and emotional abuse, neglect and misappropriation. The education also included reporting timelines and completing a thorough investigation. Licensed staff was educated on notification of family and physician related to any type of abuse beginning 8-20-11. All shifts including routine and those on 4-2 rotation will be covered to assure that all staff have been re-in-serviced prior to returning to work. The Administrator will be re-educated on abuse reporting and completing a thorough investigation 8-20-11 by the Regional Vice President of Operations. A retrospective audit, including June 2011 forward will be conducted by the Clinical Services Director, which will include the abuse log which includes resident name, date reported, date of incident, type of allegation of abuse, family notified, physician notified, initial reporting, 5 day reporting, care plan reviewed, substantiated or not, date resolved and comments. To be completed by 8-22-11. Residents will be assessed for any further allegations of abuse and documented in the clinical record. Non interviewable residents will be assessed for signs and symptoms of abuse and documentation of the assessment to be placed in the clinical record. To be done by facility Social Worker assisted by Clinical Services Director and Administrator. Incident reports will be reviewed daily for possible allegation of abuse or injuries of unknown origin. Any area of concern will immediately be opened as an investigation and reported to the state by regulation. The facility will initiate an investigation and suspend any possible employees related to the incident pending investigation. The Administrator will be responsible for monitoring this process. All allegation potential or actual will be reported to the Clinical Services Director. The facility will recruit and hire a Risk Management Nurse. Included in his/her duties will be timely and thorough investigations of all allegations of abuse, neglect or misappropriation. When hired the Risk Management Nurse will function as the Abuse Coordinator. The Risk Management Nurse will be responsible for facility wide education for all current employees and new employees related to abuse, neglect and misappropriation. This nurse will also review all incident/accidents for possible need for further investigation. The facility will do a retrospective review of the grievance logs back to June and July. Facility residents with allegations of abuse/neglect will be reported timely to the Administrator/Director of Nursing and Social Services. Allegations of abuse will be investigated as per policy and reported timely to appropriate agencies per the regulation. Facility staff and agency staff were re-educated on abuse, neglect and misappropriation. No staff will be permitted to work until they completed the education. Audits will be completed weekly and presented to the performance improvement committee monthly. Any areas of concern will be corrected at the time of discovery. The Administrator will monitor this practice on an ongoing basis. Based on interviews with facility staff, the facility had inserviced staff on facility policy on reporting, thorough investigating allegations of abuse and to whom to report such allegations. The facility had also inserviced staff on protecting residents. While the Immediate Jeopardy was removed on 8/22/11, the facility remained out of compliance at a level of potential for no more than minimal harm, with a scope identified as a pattern. The facility remained out of compliance due to not all of the staff had been in-serviced regarding the reporting of all allegations and thoroughly investigate all allegations of abuse. Review of the facility submitted form, untitled, dated 8/17/11, documented a census of 30 on Resident #9's hall.