Every finding on record at Lampstand Nursing and Rehabilitation

Based on interview and record review, the facility failed to notify the resident and resident's representative(s) of the discharge, reasons for the move, and right to appeal in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 (Resident #1) of 5 residents reviewed for discharge planning. The facility failed to notify Resident #1's RP of Resident #1's discharge, reasons for the move, and right to appeal in writing, in a language and manner they understand, as soon as practicable before the discharging Resident #1 on 04/23/2026 to another facility. The facility failed to send a copy of the notice of Resident #1's discharge to the facility's Ombudsman as soon as practicable before discharging Resident #1 on 04/23/2026 to another facility. This failure could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services. Findings included: Record review of Resident #1's face sheet, dated 07/15/2026, revealed a fifty-four-year-old female who was admitted to the facility on [DATE] with a diagnosis that included brief psychotic disorder (a short-term mental health condition defined by the sudden onset of psychotic symptoms-such as delusions, hallucinations, disorganized speech, or catatonic behavior), schizoaffective disorder (a chronic mental health condition characterized by a combination of schizophrenia symptoms (like delusions or hallucinations) and mood disorder symptoms (like depression or mania)), bipolar disorder, current episode manic severe with psychotic secondary features (a mental health condition with major mood shifts, currently experiencing high-energy mania marked by racing thoughts, reduced sleep, and impulsive actions. The manic state causes major disruption in daily life, work, or safety, often requiring hospital care. A break from reality involving hallucinations or delusions (such as false beliefs of grand power or importance)). Record review of Resident #1's care plan revealed care plan cancelled dated 04/27/2026 had a focus of Resident #1 was at risk for elopement as evidenced by exit seeking and voiced wanting to leave dated 04/16/2026 with intervention dated 04/18/2026 placed 1:1 for 48 hours. Resident #1's care plan did not include discharge planning. Record review of Resident #1's MDS Resident Assessment and Care Screening dated 04/22/2026 Section C - Cognitive Patterns reflected a BIMS score of 0 indicating severe cognitive impairment, section E0900. Wandering - Presence and Frequency - Behavior of this type occurred 4 to 6 days, but less than daily, and E1000. Wandering - Impact the wandering placed the resident at significant risk of getting to a potentially dangerous place (e.g., stairs, outside ofthe facility). Record review of Resident #1's progress notes dated 04/18/2026 reflected Resident #1 walked around front lobby. Staff was watching resident closely due to her recent outburst about wanting to leave this hospital. When visitor went to punch in door code, resident approached him. Staff let visitor know that resident could not go outside without a staff member. Resident #1 agreed to come to common area to listen to piano music that volunteer is playing. Let the ADON know of behavior. Interventions: Encourage activities, Music or sensory stimulation, Review of Resident #1's progress note dated 04/18/2026 reflected Resident #1 wandered down hallway. Resident stated she did not know where she was or how she got here. Resident #1 entered her room and then left and wandered down hallway. Resident #1 was redirected by staff. Review of Resident #1's progress note dated 04/19/2026 reflected Resident #1 was up wandering in hallway. Resident #1 noted trying to enter other residents' rooms. Resident #1 redirected back to her room. Staff encouraged Resident #1 to lie down and get some rest. Resident #1 would lie down for several minutes at a time and then get back up and go to nurses' station or wander down hallway. Staff had to redirect Resident #1 multiple times. Review of Resident #1's progress note dated 04/19/2026 reflected staff heard door alarm sound and followed the sound. A resident informed staff that a lady was outside. Nurse sent a CNA to the hallway where the alarm sounded while nurse when to the front of the building and walked outside. Nurse entered building through hall 4 and saw CNA walking with Resident #1 on hall 4. Staff asked Resident #1 what she was doing. Resident #1 said she held the door for 15 seconds. Resident #1 was placed on 1:1 (means a dedicated staff member is assigned continuously to watch and assist a single resident). Review of Resident #1's progress note dated 04/19/2026 reflected staff spoke with Resident #1's RP about Resident #1 exiting out the door and coming back in and someone sitting with Resident #1 1:1. Review of Resident #1's progress note dated 04/19/2026 reflected elopement/Attempt interventions: 1:1 monitoring, Review of Resident #1's progress note dated 04/19/2026 reflected Resident #1's RP informed that the SW was seeking a secure unit for Resident #1 because she was exit seeking. Review of Resident #1's progress note dated 04/22/2026 reflected elopement/attempt follow-upcurrently increased wandering, Resident #1 continued to wander around entire facility. Interventions: 1:1 monitoring. Review of Resident #1's progress note dated 04/22/2026 reflected Resident #1's RP was notified that Resident #1 had been accepted into another SNF with a secure unit. The RP requested that Resident #1 be discharged to a SNF closer to [another city]. The Social worker called several SNFs to see if they had a secure unit and only 2 had a secure unit but they had not responded. Clinicals were sent to other SNFs. Review of Resident #1's progress note dated 04/23/2026 reflected elopement note - follow-upCurrently exit seeking, no further elopement attempt, resident still 1:1. Record review of Resident #1's Discharge Summary by LVN A reflected on 04/23/2026 Resident #1 was transferred to another SNF with a secure unit. Discharge summary reflected no physician signature. During an interview on 07/15/2026 at 11:17 AM with the RNC she said it was the responsibility of the team together to discharge residents, both the nursing team and the SW. The RNC said she did not see any information in Resident #1's EMR that Resident #1's RP received written communication about Resident #1's discharge or that the Ombudsman was notified. The RNC said because the DON was out of the building it was the responsibility of the Administrator to make sure the discharge went smoothly. The RNC said the facility should have followed their policy when Resident #1 was discharged . The RNC said a possible negative effect of not following a discharge policy was that the RP might not have known where the Resident went. During an interview on 07/15/2026 at 1:16 PM with Resident #1's RP she said she did not want Resident #1 moved out of the facility and into the facility she was transferred to. Resident #1's RP said she was not okay with moving Resident #1 to the facility she is currently living in and she fought with the facility about moving Resident #1. The RP said the facility told her Resident #1 had to go to the place Resident #1 was sent. Resident #1's RP said she asked about other SNF locations. Resident #1's RP said the facility insisted Resident #1 go to the facility she was sent to. Resident #1's RP said Resident #1 had just gotten to the facility and Resident #1 was just getting adjusted. Resident #1's RP said she could not remember who she spoke with at the facility, but she spoke with them 2 or 3 times with phone calls going back and forth. Resident #1's RP said she was told by the facility that Resident #1 had to go there because there was nowhere else for her to go. Resident #1's RP said she never received any information in writing about Resident #1's discharge and was never told that she could contact the Ombudsman or that she had the right to appeal the discharge. During an interview on 07/15/2026 at 12:48 pm with the SW said she had worked for the facility for 1 month and after reviewing the facility policy stated the facility needed to document that the family was notified in writing or received a written email providing residents 30 days prior to discharge or given notice as soon as possible about the discharge. She said the Resident's medical physician and the Ombudsman needed to be informed about resident discharges. The SW said she was new and was familiarizing herself with the facility policies and procedures. The SW said a possible negative effect of not following the facility discharge policy was miscommunication and issues with the safety and health of the residents in addition to possible misinformation to the new facility. During an interview by telephone on 07/15/2026 at 12:56 pm with the FSW she said they needed to get Resident #1 to a building that had a secure unit. The FSW said Resident #1's RP wanted a placement closer to her but the only facility closer to Resident #1's RP did not have availability. The FSW said Resident #1's RP complained that Resident #1 was going too far away. The FSW said she did not get the Ombudsman involved with discharging Resident #1 and she did not remember why. The FSW said she did not send Resident #1's RP or the Ombudsman anything in writing. The FSW said she just spoke to Resident #1's RP on the phone and put a note in Resident #1's progress notes. The FSW said she did not give Resident #1 notice about an appeal process. The FSW said they only give notice to the Ombudsman and information goes to the RP only if a 30-day discharge notice was given. During an interview by telephone on 07/15/2026 at 1:35 PM LVN A said she did not remember doing the discharge paperwork for Resident #1. During an interview by telephone on 07/15/2026 at 2:00 PM with the PMHNP-BC she said when the facility decided to transfer a resident to another facility, they transferred the resident. The PMHNP-BC said it was not for her to decide about resident transfers. The PMHNP-BC said it was obvious to her that Resident #1 was exit seeking and she absolutely thought that Resident #1 needed a secure unit. During an interview on 07/15/2026 at 2:08 PM with the Administrator who began working at the facility on 06/30/2026 he said he called the FSW and discussed Resident #1's discharge and the FSW told him that Resident #1 needed to be transferred to a SNF with a secure unit. He said after talking with the FSW he felt like it was an emergent situation and the FSW documented the discharge in Resident #1's progress notes on 04/22/2026. The Administrator said written notice to Resident #1's RP was not needed because it was an emergent situation and for Resident #1's safety. The Administritor said that notification to Resident #1's RP of the resident's right to appeal was not necessary because the situation involved Resident #1's safety. The Administrator said in their May 2026 notice to the Ombudsman about facility discharges, they did provide notice of Resident #1's discharge to another skilled nursing facility. The Administrator said Resident #1's discharge was not a discharge, but a transfer because Resident #1 was transferred to a sister facility. During an interview by telephone on 07/15/2026 at 2:30 PM with the MLO for the facility area she said she received notice of Resident #1's discharge on the 05/01/2026 monthly discharge report. She said this monthly discharge report was a report that was submitted to her every month from each SNF for which she was the Ombudsman. The MLO said that for each discharge, written notice should be given to the resident or the resident's RP and the Ombudsman in writing. The MLO said these notices should include the reason why the resident was being discharged . The MLO said each resident or the RP for that resident who is being discharged should receive a notice of their right to appeal the discharge. During an interview by telephone on 07/15/2026 at 3:45 PM with the DRO she said even in urgent situations a written notice of a copy of the discharge documentation giving the specific reason the facility gave for the immediate discharge must be sent to the resident or the resident's RP and to the Ombudsman before or immediately upon the emergency move. The DRO said these requirements are for the residents' protection at discharge. She said a negative impact of not providing the information for the resident or the resident's RP right to appeal would be a possible uprooting of a resident and the loss of the primary support and the psychological confusion to the resident being moved to a different environment. On 07/15/2026 at 4:06 PM an attempt to call the former facility Administrator leaving a voice mail and a text message. No response to messages received. Record review of facility Discharge or Transfer Facility Initiated discharge date d 02/12/20-25 reflected the facility will permit each resident to remain in the facility and not transfer or discharge the resident from the facility. In the following limited circumstances, this facility may initiate transfers or discharges:The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; To demonstrate that any of the circumstances are permissible for a facility to initiate a transfer or discharge as specified in A, the medical record will show documentation of the basis for transfer or discharge. This documentation must be made before, or as close as possible to the actual time of transfer or discharge. For circumstances A for permissible facility-initiated transfer or discharge, the resident's physician must document information about the basis for the transfer or discharge. Additionally, for circumstance A above, the inability to meet the resident's needs, the documentation made by the resident's physician must include:The specific resident needs the facility could not meet;The facility efforts to meet those needs; andThe specific services the receiving facility will provide to meet the needs of the resident which cannot be met at the current facility. Long-Term Care Regulation Provider Letter Nursing Facility Resident Discharge and Appeal dated 09/29/2022 reflected the purpose of this letter is to provide guidance to Nursing Facilities regarding resident discharges and discharge appeal hearings. Providing clear notice and documentation during a discharge are legal requirements and essential to protecting the rights and dignity of residents. Reasons for Discharge Permitted by Rule A - Nursing Facility must determine its capacity and ability to care for a resident upon admission. The facility must allow a resident to remain in the facility and may not involuntarily discharge the resident unless the transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility. Proper Discharge Notification if a Nursing Facility initiates a resident discharge, the facility must provide written notification of the discharge-in a language and manner the resident can understand-to the resident, the resident representative (if applicable), and a representative of the Long-Term Care Ombudsman Program, at least 30 days before the intended discharge date . The discharge notification must include: the reason for the discharge; the effective date of the discharge; the location to which the resident is being discharged ; a statement that informs the resident of his or her rights to appeal the discharge by requesting a hearing through the Health and Human Services Commission (HHSC) within 90 days; information on how to obtain an appeal form and assistance in completing and submitting it; contact information of the managing local ombudsman and the toll free number for the Long-Term Care Ombudsman Program, which is [PHONE NUMBER]; if applicable, for residents with a mental illness, contact information of the state mental health authority; and if applicable, for residents with an intellectual or developmental disability (IDD), contact information for the authority for individuals with IDD, along with the contact information for the agency responsible for the protection and advocacy of individuals with IDD.3 A Nursing Facility must provide a discharge notice as soon as practicable before the 30-day period described above if: the safety of an individual in the facility would be endangered; the health of an individual in the facility would be endangered; the discharge is necessary for the resident's welfare because the resident's needs cannot be met in the facility; A Nursing Facility should provide as much specific information as possible in the discharge notice to notify the resident why he or she is being discharged and how the discharge meets discharge criteria as outlined in rule. The statement of the resident's appeal rights must inform the resident that he or she has the right to appeal the action as outlined in HHSC's Fair and Fraud Hearings Handbook by requesting a hearing within 90 days of the date of the notice; provide information on how to obtain an appeal form and assistance in completing the form and submitting the fair hearing request; and inform the resident that, if the resident requests the hearing before the discharge date , the resident has the right to remain in the facility until the hearings officer makes a final determination unless failure to discharge would endanger the health or safety of the resident or individuals in the facility. The facility must document how a failure to discharge a resident would present a danger to the resident or others. A Nursing Facility is required to provide a resident with enough preparation regarding his or her discharge so that it may be safe and orderly. Appropriate preparation can include]explaining the discharge to the resident in a manner that he or she can understand; working with the resident or the resident's representative to ensure all the resident's personal belongings are collected; and ensuring NF staff handle the discharge in a way that will ease the transition for the resident. A NF must provide the resident with a discharge summary that includes: a summary of the resident's overall stay; the status of his or her permanent medical necessity under the Medicaid program with a new medical necessity determination; and a post-discharge plan of care that will assist the resident to adjust to the new living environment. Resident's Right to a Fair Hearing Regardless of the reason for discharge, a resident has the right to appeal a discharge within 90 days of a discharge notice. If the resident appeals before the discharge date , the facility may not discharge the resident while the appeal is pending. A NF is required to allow the resident to remain in the facility until the hearing officer makes a final determination unless the transfer and discharge is necessary for the resident's welfare because the resident's needs cannot be met in the facility.

Based on interviews and record review the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical status for one (Resident #1) of seven residents reviewed for resident rights. The facility failed to ensure ADON A notified the resident's responsible party/medical power of attorney within a reasonable time when Resident #1 fell out of bed on 06/12/2026. This failure could place residents at risk of not having their responsible party/medical power of attorney notified of changes, which could result in a delay in timely intervention and a decline in condition. Findings included: Record review of Resident #1's Face Sheet dated 06/23/2026 reflected a [AGE] year-old female with an admission date of 06/04/2026. Her diagnoses included unspecified fracture of right femur (break in thigh bone), anemia in chronic kidney disease (kidneys are damaged and cannot filter blood), and cognitive communication deficit (attention, memory, and reasoning declines making it hard to organize thoughts). Record review of Resident #1's MDS dated [DATE] indicated Resident #1 had a BIMS of 14, indicating cognitively intact. Record review of Resident #1's care plan initiated on 06/05/26 reflected that the resident was at risk of falls with interventions that included, keep needed items within reach and Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. Record review of Resident #1's Nurse Progress note dated 06/12/26 at 5:26 AM by ADON A, reflected Resident observed calling for help. Upon entering room, resident was on floor wrapped in her blankets. When asked how she ended up on the floor, resident stated, I was trying to get up and rolled off the bed. Record review of Resident #1's fall notification dated 6/12/2026, completed by ADON A in the electronic health record reflected the DON and physician were notified on 6/12/2026 at 5:24 am. and the resident's responsible party/medical power of attorney was notified on 06/12/2026at 18:00 (6:00 PM).Record Review of the facility's accident/incident reported dated 6/23/2026 reflected Resident #1 had a fall at 4:00 AM on 6/12/2026. In an interview conducted on 06/23/2026 at 10:28 AM with Resident #1's responsible party/medical power of attorney, who stated the resident fell on 6/11/2026 at 4:00 AM and the facility staff did not notify her of the fall until 24 hours later on 06/12/2026 at 6:00 PM. It was stated to the responsible party that the record showed Resident #1's fall was on 06/12/2026 instead of 06/11/2026. She stated the facility should communicate in a more appropriate time frame. In an interview with ADON A conducted on 06/24/2026 at 12:03 p.m., she stated he had been employed at the facility for five years. She stated the facility's fall protocol requires staff to assess the resident for injuries, notify the physician, the resident's family or responsible party, and the DON. She further stated the administrator is notified if the resident sustains an injury. ADON A stated the resident's family or responsible party should be notified immediately following a fall. ADON A stated she was unable to notify the resident's responsible party because she was unable to leave a voicemail message. She stated that, because she was leaving work, she asked the oncoming nurse, RN B, to notify the responsible party. ADON A was advised that her nursing documentation in the resident's electronic medical record indicated she was the one who had notified the responsible party 06/12/2026 at 6:00 p.m . ADON A did not have a response. ADON A stated she does not know of any potential harm that could happen to the resident but stated, it is important for the resident's family or responsible party to be notified promptly so they are aware of what is occurring with their loved one at all times. In an interview with RN B conducted on 06/24/2026 at 12:23 p.m., she stated she had been employed at the facility for five months. RN B stated she did not recall being asked to notify anyone regarding Resident #1's fall that occurred on June 12, 2026 . She stated that following a resident fall, proper notifications should be made immediately to the nurse practitioner, the DON, and the resident's family or responsible party. RN B further stated the resident would be assessed first following the fall and that all appropriate individuals should be promptly notified and made aware of the resident's condition. In an interview conducted with the DON on 06/24/2026 at 12:41 PM, she stated she has been with the facility for 6 years. She stated the nursing staff was to complete a fall risk assessment after every fall. The DON stated there is not a specific time frame, but the nurse practitioner, physician, and resident's responsible party should be notified once the resident is stable, not hours later. The DON stated her expectation is for the staff to notify all parties immediately. Record review of the facility's policy titled, Fall Policy undated reflected: Fall PolicyPreventing falls requires an interdisciplinary program that focuses on modifying the extrinsic factors, correcting intrinsic factors, and educating the resident and family. A Fall Risk Assessment will be completed on admission and after each fall. The MDS 3.0 will also assist in determining a resident who is a fall risk. 13. In instances where fall risk measures do not prevent a fall, the resident will be assessed immediately for injury. Vital signs and first aid measures will be completed immediately. The Charge Nurse will notify the attending physician and family member as soon as possible after the resident has been stabilized .

Based on observation, interview, and record review the facility failed to ensure that the resident environment remained as free of accidents and hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents hazards and supervision. The facility failed to ensure that Resident #1's bed was in low position, and his alternating air mattress was with the correct settings when Resident #1 experienced an unwitnessed fall on 06/05/2026 at 07:34 PM. This failure could place residents at risk for falls with the possibility of injury, including fractures.Findings included: Review of Resident #1's admission record, dated 06/09/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] and most recently readmitted on [DATE], with diagnoses that included: pressure ulcer of sacral region (an pressure sore to the area just above the buttocks on the lower back), osteomyelitis (an infection in the bone), and end stage renal disease (a chronic condition in which the kidneys lose nearly all of their filtering ability). Review of Resident #1's Quarterly MDS, dated [DATE], reflected a BIMS score was not completed because Yes was selected for Persistent vegetative state/no discernible consciousness. Section M - Skin Conditions reflected Resident #1 had a pressure ulcer/injury and used a pressure reducing device for the bed. Review of Resident #1's care plan, dated 01/30/2026 and last revised on 02/10/2026, reflected a focus of The resident is risk for falls r/t incontinence, Unaware of safety needs with an intervention that included The resident needs a safe environment with: (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; hand rails on walls, personal items within reach). Review of Resident #1's care plan, dated 01/30/2026 and last revised on 04/01/2026, reflected a focus of The resident has a stage 4 pressure ulcer [a pressure ulcer that extends through all layers of the skin and down to the muscle/bone] with an intervention that included The resident requires the use of an air mattress. Review of Resident #1's care plan, dated 01/30/2026 and last revised on 06/06/2026, reflected a focus of The resident has a pressure ulcer with an intervention that included Resident has an alternating air mattress on his bed Review of Resident #1's order summary, dated 06/09/2026, reflected the following orders: May have pressure relieving mattress every shift with a start date of 01/29/2026; May use air mattress d/t pressure ulcer. Check for proper functioning q shift, ensure weight setting is correct, and it is ALT airflow not static. Static is only used during ADL care every shift with a start date of 06/08/2026; May use bolsters [a long, thick pillow or other similar shaped item used to provide support for positioning] to bed every shift for prevent unintentional rolling out of bed with a start date of 06/09/2026; Resident may use air mattress on bed with a start date of 01/29/2026. Record review of Resident #1's progress notes dated 06/05/2026 at 07:34 PM written by the ADON reflected Resident had a fall. Location: Resident Room.Fall information: Unwitnessed, Discovered on floor, Next to bed,Cognition / Behavior at Time of Event:The fall caused a skin tear to below left eye, bridge of nose, Size of the skin tear in cm:0.1x0.1 nose, 2x .1 cm below eye, New / bleeding, . Nurse standing in doorway of 211. Hear a loud bang noise, entered room [Resident #1's room number] and notice resident was lying on the floor left side of bed facing the door. Notice blood on the floor and coming from face, resident eyes open, awake. Was able to assess resident and roll him over. Used draw sheet to pick resident up off the floor. Record review Resident #1's hospital discharge instructions, dated [DATE], provided by the facility reflected FINAL DIAGNOSIS, s/p fallADDITIONAL DIAGNOSISclosed head injury [a head injury that does not break the skull - See CT scan results below]left facial abrasions [an open wound caused by friction]periorbital contusion [bruising around the eye] . Record review of Resident #1's hospital record, dated 06/05/2026, provided by local hospital reflected Resident #1 weighed 77.4 kg (170.28 pounds). A CT scan of the facial bones reflected the following impression (result or finding): Mildly displaced depressed left nasal bone fracture. A CT scan of the brain reflected the following impression: No appreciable acute intracranial abnormality [No injury to the brain]. The nursing assessment reflected Skin:.Inspection findings include swelling, to left eye, small laceration to left eye sustained after fall from bed. Record review of facility in-service titled Abuse & Neglect, Q 2 Rounding, Fall Prevention, Fall Risk, Pain Management, Air Mattress Settings, Residents Positioning, dated 06/06/2026, reflected the following: Abuse & Neglect: .Q 2 hour rounding: .Fall Prevention: .Fall Risk: .Air Mattress Settings: It is important to ensure every air mattress is set to the resident's correct weight. Proper weight settings allow the mattress to provide the appropriate pressure redistribution, which helps reduce the risk of skin breakdown and pressure injuries. Incorrect settings can also affect the resident's positioning and stability in bed, increasing the risk of falls and discomfort. Nursing staff should verify the resident's weight and check mattress settings regularly, especially after admissions, significant weight changes, or when concerns about skin integrity arise.Resident Positioning and Fall Prevention: When repositioning a resident in bed, it is important to ensure the resident is centered in the middle of the mattress. Proper positioning helps prevent the resident from being too close to the edge of the bed, reducing the risk of falls and injuries. Centering the resident also promotes comfort, maintains proper body alignment, and allows the mattress to provide effective pressure redistribution. Staff should verify the resident's position after every transfer, repositioning, and care activity to ensure safety.Observation on 06/09/2026 at 09:05 AM revealed Resident #1 lying in bed on a low air loss mattress with the bed approximately 8-10 inches off the floor. Resident #1 was observed with swelling to the bridge of his nose and his left eye with surrounding bruising and a linear scab across the bridge of his nose that continued just below the left eye to the outer corner. There were fall mats on the floor on each side of the bed. There was a piece of tape covering the setting on the air mattress pump and a sign that reflected Do not adjust settings taped to the machine. The settings on the pump were set to approximately 170 pounds.During observations performed on 06/09/2026 between 11:30 AM and 1:00 PM, 3 observed air mattresses in the facility with settings set correctly for their corresponding residents. During an interview on 06/09/2026 at 03:10 PM, the ADON stated she was working on 06/05/2026 at 07:34 PM when Resident #1 sustained a fall. She stated she was in the doorway of an adjacent room and heard a loud noise. She stated she locked her cart and went down the hall to find the source of the noise and could see Resident #1 on the floor on the opposite side of the bed from the doorway. She stated she immediately assessed Resident #1 and noticed a laceration across the bridge to his nose, under his left eye, and to the outer corner of his left eye that was bleeding. The ADON stated she got assistance from other staff members to get Resident #1 back into bed and called the practioner for a tele visit consultation. She stated the practioner gave orders to send Resident #1 out to the emergency room for evaluation. The ADON stated Resident #1 returned to the facility on [DATE] around 04:00 AM with discharge papers that reflected diagnoses of status post fall, closed head injury, left facial abrasions and periorbital contusion. The ADON stated she was not aware of any fractures that occurred as a result of the fall. She stated the bed was about waist height off the floor, so it was higher than was needed to keep his Foley catheter off the floor, and the air mattress settings were set for a resident who weighed 220 pounds and Resident #1 weighed about 170 pounds. She stated the footing of the machine next to his bed appeared to have caused the injury with bleeding. The ADON stated CNA A was in Resident #1's room approximately one hour prior to the fall to provide care and repositioning. She stated Resident #1 had not had any decline in condition or change in demeanor since the fall. During an interview on 06/09/2026 at 04:12 PM, CNA A stated she had worked with Resident #1 on 06/05/2026 and had provided care and repositioned him around 06:30 PM. She stated she left Resident #1 positioned on his left side in the middle of the bed with the wedge pillow behind his back and pillows under and between his knees. She stated she left the bed about a foot off the ground, but she did not look at or touch the air mattress pump while in Resident #1's room. CNA A stated she knew Resident #1 was on an air mattress and they were set to the resident's weight, but she didn't know anything else about the air mattresses. She stated she clocked out for break and was notified during her break that Resident #1 had a fall. During an interview on 06/09/2026 at 04:39 PM, the DON stated Resident #1 had a fall on 06/05/2026. She stated she had discovered that the ADON was near the room, but no staff were in the room when Resident #1 fell from bed. She stated the ADON heard a noise and after looking for the source of the noise she found Resident #1 on the floor next to his bed. The DON stated she thought the cause of the fall was the alternating air loss mattress. She stated the mattress worked by the air inflating and deflating in cycles on each side of the bed. The DON stated that it could be possible for the mattress to flip someone out of bed. The DON stated the ADON told her the bed was about 2 feet off the ground when Resident #1 fell out of bed. She stated the fall precautions in place for Resident #1 were to keep the bed in low position, but the facility had to be careful about how low to put the bed due to all of the machines that Resident #1 required. The DON stated the injuries Resident #1 received during the fall were a swollen eye and a cut across the bridge of his nose that went over to the outer corner of his eye. She stated the discharge instructions and report received from the emergency room did not indicate any fracture had occurred. The DON stated the Administrator was on leave. Review of, undated, facility policy titled Fall Policy reflected Preventing falls requires an interdisciplinary program that focuses on modifying the extrinsic factors, correcting intrinsic factors, and educating the resident and family. A Fall Risk Assessment will be completed on admission and after each fall. The MDS 3.0 will also assist in determining a resident who is a fall risk.Appendix A Fall Intervention MethodsEnvironmental.Bed height needs to be appropriate height with wheels locked.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of three residents (Resident #1) reviewed for catheter care. The facility failed to ensure Resident #1's urinary drainage bag was found hanging from the bed frame with the bottom of the bag touching the floor/floor mat on two occasions on 06/09/2026. This failure could place residents with indwelling catheters (a tube that is inserted through the urethra to the bladder to drain urine) at risk of developing infections.Findings included: Review of Resident #1's admission record, dated 06/09/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] and most recently readmitted on [DATE], with diagnoses that included: pressure ulcer of sacral region (an pressure sore to the area just above the buttocks on the lower back), osteomyelitis (an infection in the bone), and end stage renal disease (a chronic condition in which the kidneys lose nearly all of their filtering ability). Review of Resident #1's Quarterly MDS, dated [DATE], reflected a BIMS score was not completed because Yes was selected for Persistent vegetative state/no discernible consciousness. Section H - Bladder and Bowel reflected Resident #1 had an Indwelling catheter. Review of Resident #1's care plan, dated 01/30/2026 and last revised 02/10/2026, reflected a focus of The resident has Indwelling Catheter: 18FR/10cc with an intervention that included Check tubing for kinks and maintain the drainage bag off the floor. Review of Resident #1's order summary, dated 06/09/2026, reflected the following orders: Empty foley drainage bag every shift with a start date of 02/26/2026; Foley Catheter: 18_F with _10_bulb - change for occlusion, leaking, closed system was compromised one time a day every 30 day(s) with a start date of 01/29/2026; Monitor F/C q shift for leakage, blockage, sediment buildup, or low output every shift with a start date of 01/29/2026. Observation on 06/09/2026 at 09:05 AM revealed Resident #1 lying in bed on a low air loss mattress with the bed approximately 8-10 inches off the floor. Resident #1's urinary drainage bag was hanging from the bed frame on the right side near the foot of the bed and the bottom of the bag was touching the floor. Observation on 06/09/2026 at 12:31 PM revealed Resident #1 lying in bed on a low air loss mattress with approximately 8-10 inches off the floor. Resident #1's urinary drainage bag was hanging from the bed frame on the right side near the foot of the bed and the bottom of the bag was resting on the fall mat next to the bed. During an interview on 06/09/2026 at 03:10 PM, the ADON stated she had been trained in the care of an indwelling catheters. She stated she was trained that the urinary drainage bag is to hang from the frame of the bed but not be allowed to touch the floor. The ADON stated if the urinary drainage bag were allowed to touch the floor, then it could cause contamination and possible infection in the resident. She stated the charge nurses were responsible for monitoring to ensure the urinary drainage bags were hung on the bed frame but were not touching the floor during their rounds. During a phone interview on 06/09/2026 at 03:53 PM, CNA B stated she had been trained to provide care to indwelling catheters, and it was important to ensure that the urinary drainage bag did not touch the ground because it could contaminate the bag and cause infection in the resident. She stated all staff were responsible for monitoring the placement of urinary drainage bags during their rounds. CNA B stated she was responsible for providing care to Resident #1 on the morning of 06/09/2026. She stated Resident #1's urinary drainage bag kept falling on the ground that morning and she had checked it several times that day. During an interview on 06/09/2026 at 04:04 PM, RN C stated she had been trained to keep the urinary drainage bag hung so that it did not touch the floor because the bacteria on the floor could cause an infection in the resident. She stated she was the nurse in charge of Resident #1 on 06/09/2026 and did not see his urinary drainage bag touching the floor. RN C stated it was the responsibility of all staff to monitor for the correct placement of urinary drainage bag during their rounds. During an interview on 06/09/2026 at 04:12 PM, CNA A stated she had been trained to provide care for indwelling catheters. She stated she was trained to ensure the urinary drainage bag was to be hung where it did not touch the floor because touching the floor could contaminate the bag and cause an infection in the resident. She stated it was the responsibility of all direct care staff to monitor the urinary drainage bag was hung properly when they did their rounds. During an interview on 06/09/2026 at 04:39 PM, the DON stated she expected direct care staff to ensure that urinary drainage bag did not touch the ground or floor mat. She stated if the bag touched the ground or floor mat then the resident could potentially develop an infection. She stated management was responsible for monitoring to ensure proper placement of urinary drainage bag during their rounds. She stated the CNAs are educated to know the expectation of where to hand the urinary drainage bag. The DON stated the Administrator was on leave during the investigation. Review of, undated, facility policy titled Catheter Care reflected General Guidelines.10. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on interview, and record review, the facility failed to ensure residents could exercise their rights without interference for 1 of 10 residents (Resident #1) reviewed for resident rights. The facility failed to prevent staff from obscuring the view of an authorized electronic monitoring device in Resident #1's bedroom on 05/28/2026. This failure placed residents at risk of abuse, neglect, or maltreatment not being identified.Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included traumatic brain injury, schizophrenia, seizure disorder, and major depressive disorder. Review of the quarterly MDS assessment for Resident #1 dated 05/01/2026 reflected he could not participate in the BIMS assessment due to cognitive impairment. Review of the care plan for Resident #1 dated 09/15/2025 reflected the following: FOCUSResident/Resident's responsible party has requested electronic monitoring.GOALResident/Responsible party will have electronic monitoring in place through review date.INTERVENTIONS-Educate resident/responsible party of their responsibility associated with electronic monitoring including:-Reporting abuse/neglect within 14 days of viewing surveillance or being informed of abuse/neglect by a person(s) viewing video surveillance of what they believe to be abuse or neglect.-Providing a copy of surveillance to facility administration as requested.-Educate resident/responsible party of their responsibility associated with electronic monitoring including:-The need to pay for all costs associated with electronic monitoring (other than cost of electricity); including installation in compliance with life safety and electric codes, maintenance, removal, and repair of equipment.-Make reasonable accommodation for electronic monitoring to be placed by resident/responsible party, including power supply.-Obtain consent from resident's roommate/Responsible party (if applicable) for electronic monitoring-Place conspicuous notice of electronic monitoring at entrance of room. Review of a video dated 05/28/2026 at 6:36 AM reflected two staff members (CNA B and CNA C) entering Resident #1's room and closing the privacy curtain so that it obscured the view of Resident #1, the CNAs, and the bed. What was occurring behind the privacy curtain was not visible, and the noises were not distinguishable. The recording ended with the privacy curtain still closed. During an interview on 05/30/2026 at 5:12 PM, the RP for Resident #1 stated the facility had been instructed many times not to obscure the view of Resident #1 from the camera, even when he was provided incontinent care. She stated she had seen examples of the staff pulling the privacy curtain closed to provide care despite her repeated requests that they not. She stated she did not have older videos to this effect, but she still had one from 05/28/2026. She stated she did not trust the staff to provide adequate care for Resident #1, so she wanted to observe all care to make sure. During an interview on 06/01/2026 at 10:56 AM, CNA B stated she was one of the aides helping Resident #1 in the video from 05/28/2026. She stated they always had to provide help for him with two people present due to a history of allegations by his RP. She stated she closed the privacy curtain for Resident #1 to have privacy. She stated she had not received any instruction about not closing the privacy curtain for Resident #1. She stated she had been employed at the facility for one month. She stated she was aware the privacy curtain blocked the view of the care they provided but she thought that was the correct procedure when providing care. A telephone interview was attempted with CNA C on 06/01/2026 at 11:21 PM. A voicemail message was left and not returned as of 06/08/2026. During an interview on 06/01/2026 at 12:32 PM, the SW stated the IDT and the nursing staff had discussed that the staff were not to close the privacy curtain when providing care for Resident #1. She stated the only time they were allowed to pull the curtain was if Resident #1's RP began cursing at staff or saying ugly things to them through the camera. She stated this was a regular occurrence with the RP of Resident #1, and these were the only circumstances in which the staff were permitted to close the curtains while providing care. During an interview on 06/01/2026 at 2:09 PM, the DON stated the staff pulled the curtain to obscure the camera for Resident #1 only when she began cursing at them and/or calling them names. She stated the cursing and name-calling had an effect on the staff, and they could not do their jobs while it was going on. She stated, otherwise, the curtain was to be open with a full view of all care at all times. She stated she had in-serviced about this and spoke about it at staff meetings. She stated she was responsible for ensuring compliance, and she did so by making rounds and observing staff providing care. She stated she did not think there could have been a negative impact on the resident from having the privacy curtain closed. During an interview on 06/01/2026 at 2:58 PM, the ADM stated her understanding was the staff were told not to block the camera during care for Resident #1. She stated it was her responsibility to ensure compliance with the process, and the SW was responsible for implementing all the consents and procedures for authorized electronic monitoring. The ADM stated she monitored for compliance by performing random checks as staff entered surveilled rooms. She stated the possible negative impact on residents of having care obscured from the camera was the RP could not oversee and confirm that proper care was being provided. Review of the facility's policy dated 01/25/2024 and titled Authorized Electronic Monitoring (AEM) reflected the following: Facility and Resident Responsibilities Regarding AEMThe person requesting or using AEM must inform the facility that AEM is being requested or used. Each facility must have the proper documentation and signage in place for the monitoring and must permit a resident or their guardian or legal representative to monitor the resident's room using electronic monitoring devices.

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 3 of 7 residents (Resident #26, Resident #37, and Resident #76) reviewed for infection control. RN Treatment Nurse C did not change contaminated gloves prior to Resident #26's repositioning; contact with clean supplies; and she did not wash her hands after removing gloves post perineal care. RN B did not sanitize her hands between changing gloves while performing indwelling catheter care on Resident #37. ADON LVN F did not sanitize the over-the-bed table prior to setting supplies on it and turned her back to a sterile field multiple times while performing tracheostomy care on Resident #76. These failures could place the residents at risk of infection transmission, sepsis, and hospitalization. Findings included: A. Record review of Resident #26's face sheet, dated 04/10/2026, reflected [AGE] year-old male originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included: unspecified convulsions (sudden, involuntary, and often violent contractions of muscles, characterized by shaking, rigidity, and potential loss of consciousness), major depressive disorder severe with psychotic symptoms (a serious, common mental health condition characterized by persistent sadness, loss of interest, and low energy), and schizophrenia (a chronic, severe brain disorder causing distorted interpretations of reality, including hallucinations, delusions, and disorganized thinking). Record review of Resident #26's quarterly MDS assessment, dated 03/25/2026, reflected level 3 for cognitive skills for daily decision making indicating the severely impaired - never/rarely made decisions. Resident #26's MDS indicated his total dependance on helper for all efforts or the assistance of 2 or more helpers is required for the resident complete eating, oral hygiene, toileting hygiene, shower/bath and dressing. Record review of Resident #26's comprehensive care plan, dated 09/12/2025, reflected a focus Bowel and bladder incontinence with interventions included Provide peri care after each incontinent episode. Observation of Resident #26's peri care on 04/08/2026 at 1:26 PM. revealed RN Treatment Nurse C did not change gloves between cleaning the front and back perineal (area between the anus and the genital organs) areas of Resident #26 and touched Resident #26's clothes, body, bedding and clean incontinence brief while repositioning him with contaminated gloves. RN Treatment Nurse C removed contaminated gloves after completing Resident #26's peri care and did not wash hands before lowering resident's bed and moving privacy curtains, and opening resident's door. She did not wash her hands before and after leaving his room but sanitized her hands using a wall mount hand sanitizer dispenser in the hallway. During an interview on 4/08/2026 at 1:34 PM, RN Treatment Nurse C stated that she worked at the facility for three years and had an in-service on hand hygiene and infection control sometimes last month and she was supposed to change gloves between front and back peri area and wash hands with soap and water after taking gloves off and before leaving Resident #26's room. She stated that she forgot a hand sanitizer and was nervous during peri care observation by the surveyor. She stated that not washing hands and changing gloves according to the facility's policy could lead to cross contamination and infection control issues that could negatively affect residents. B. Record review of Resident #37's admission record, dated 04/10/2026, reflected a [AGE] year-old male originally admitted on [DATE] and readmitted on [DATE] with diagnoses of seizures (sudden, uncontrolled bursts of electrical activity in the brain that cause temporary changes in behavior, movement, sensation), acute prostatitis (a sudden, severe bacterial infection of the prostate gland requiring prompt medical attention), and acute cystitis without hematuria (an infection of your bladder without blood in urine). Record review of Resident #37's comprehensive care plan, dated 12/02/2025, reflected a focus: indwelling catheter in place (a flexible tube placed in the bladder to continuously drain urine into an external bag, held in place by a water-filled balloon) with indicated interventions: provide catheter care every shift. Record review of Resident #37's orders revealed an order, dated 12/12/2024, to provide catheter care every shift. Record review of Resident #37's quarterly MDS, dated [DATE], indicated BIMS level of 7, severe cognitive impairment, and always urinary and bowel incontinent with indwelling catheter in place During an observation on 4/10/2026 at 1:37 PM of Resident #37's indwelling catheter care performed by RN B, RN B completed hand hygiene before donning PPE and provided indwelling catheter care using clean wipe for each stroke when cleaned urinary meatus and catheter tubing. RN B did not sanitize her hands between gloves change and she touched with contaminated gloves the wipes package pulling out some additional wipes that were not out already. During an interview on 04/10/2026 at 1:45 PM, RN B stated that she had an in service on hand hygiene and infection control today. She stated that she did not sanitize her hands between changing gloves and she was not aware of facility's policy to sanitize hands between gloves change. She stated that if proper hand hygiene and infection control policy were not followed, it could negatively affect residents due to cross contamination and causing UTI. During an interview on 4/10/2026 at 9:01 AM, DON stated that she was a DON at this facility for five years. She stated that in-service on hand hygiene and infection control provided to staff on continues basis and nursing management including infection preventionist and herself were responsible for monitoring staff followed the proper protocol for hand hygiene and infection control. She stated that hands need to be washed before going to the resident's room and after completing resident direct care. She stated that hands need to be sanitized between gloves changes to prevent cross contamination. During an interview on 4/10/2026 at 9:36 AM, ADON LVN IPCP E stated she worked as an infection preventionist at the facility for 7-8 years. She stated that she was responsible for monitoring staff following facility infection control policies and providing staff in-services on infection control to protect residents and prevent the cross contamination. She stated that hand washing should be completed before going to resident's room and after completing incontinent care and before exiting the room. She stated that hand hygiene should be performed between gloves' changes. During an interview on 4/10/26 at 9:53 AM, ADM stated that she worked at the facility for 9 months. She stated that she had in-service on hand hygiene and infection control a few months ago. ADM stated that nursing management including ADONs, infection preventionist and DON were responsible for overseeing the staff adhering to proper infection control protocol and educating staff in need of additional training. She stated that hands should be washed during peri care, before touching anything in residents' environment, between gloves change, and before leaving resident's room. She stated that if not following proper infection control policy could negatively impact residents due to their vulnerable status. Review of undated facility policy titled Hand hygiene reflected: You must use soap/water for the following: (alcohol-based hand cleaner is not recommended): before and after assisting a resident with toileting (hand washing with soap and water). Review of facility policy on Perineal Care, dated 4/27/2022, reflected: 24) Doff gloves and PPE. 25) Perform hand hygiene. 26) Provide resident comfort and safety by re-clothing, straightening bedding,.and placing call light within resident's reach. Always perform hand hygiene before and after glove use. C. Record review of Resident #76's admission record, dated 04/08/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: Tracheostomy status (a tube inserted into the front of the neck to assist with breathing), hypercapnia (elevated levels of carbon dioxide in the blood), chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (a condition where the respiratory system fails to maintain adequate gas exchange leading to insufficient oxygen and/or excessive carbon dioxide in the blood). Record review of Resident #76's comprehensive MDS, dated [DATE], reflected a BIMS score was not assessed due to Resident #76 was in a persistent vegetative state. Section O - Special Treatments, Procedures, and Programs reflected Resident #76 received tracheostomy care while a resident. Record review of Resident #76's order summary, dated 04/08/2026, reflected Tracheostomy care q shift with a start date of 01/29/2026 and Suction Trach q 6 hours and PRN every 6 hours related to TRACHEOSTOMY STATUS with a start date of 01/29/2026. Record review of Resident #76's comprehensive care plan, dated 01/30/2026 and last revised on 02/10/2026, reflected a focus The resident has Tracheostomy with interventions that included Suction as necessary and Use universal precautions. Assist with coughing as needed. During an observation on 04/08/2026 at 09:17 AM, ADON LVN F entered the room, walked to the resident to visually assess Resident #76's respiratory status. She walked to the nightstand in the room and opened the drawer to withdraw supplies. She placed the trach care kit on the over-the-bed table in the room (she did not sanitize the table prior to setting supplies down). ADON LVN F walked to the bathroom and washed her hand then walked out of the room and returned shortly afterward wearing a gown and gloves. ADON LVN F used a pulse oximeter on Resident #76's left index finger. She opened the suctioning supplies including the suction catheter, sterile water bottle (partially used), and the basin for sterile water. ADON LVN F then doffed (took off) the gloves, sanitized her hands, and donned (put on) sterile gloves. ADON LVN F turned around and connected the suction catheter to the suction tubing and pulled the tracheostomy collar away from the tracheostomy site with her back to the sterile field with the supplies for tracheostomy care. She inserted the suction catheter into the tracheostomy and pulled it out. She turned back toward the sterile field to place the tip of the suction catheter inside the previously opened bottle of sterile water that she held with her left hand that was wearing sterile gloves. ADON LVN F turned her back again to the sterile field and inserted the suction catheter into Resident #76's tracheostomy. She turned back to the supplies and inserted the suction catheter into the sterile water bottle that she was stabilizing with her gloved left hand. ADON LVN F turned her back again to the over-the-bed table with supplies on it to insert the suction catheter into the tracheostomy again. She turned back to Resident #76 and removed the dressing around the tracheostomy and disposed of it in the trash bin. ADON LVN F then doffed her sterile gloves, sanitized her hands, and opened the tracheostomy care kit. She sanitized her hands again and opened a new bottle of sterile water. ADON LVN F poured sterile water from the new bottle into the tracheostomy kit's tray. She sanitized her hands and donned new sterile gloves. ADON LVN F grabbed saturated gauze from the tracheostomy care tray and turned her back to the sterile field to use the gauze to clean the area around the tracheostomy then threw the gauze in the trash. ADON LVN F turned her back to the sterile field and removed the inner cannula (plastic tube that goes inside the tracheostomy), she turned back to the sterile field to use the cotton swabs that were in the tracheostomy care kit to clean the inner cannula. ADON LVN F turned back to Resident #76 and inserted the inner cannula into the tracheostomy. ADON LVN F then changed Resident #76's necktie and aerosol line appropriately. During an interview on 04/09/2026 at 01:20 PM, ADON LVN F stated she had worked at the facility for about 7 years. ADON LVN F stated she was trained to use sterile technique when providing tracheostomy care. She stated she recalled briefly turning her back to her sterile field during the tracheostomy care. ADON LVN F stated by turning her back to the sterile field, it would not be considered a sterile field after that. She stated she did not disinfect the over-the-bed table prior to placing the tracheostomy care supplies on it, but she should have. ADON LVN F stated not maintaining sterile technique or disinfecting the surface prior to setting down her supplies could introduce bacteria to the resident. During an interview on 04/10/2026 at 12:03 PM, ADON LVN IPCP E stated she was responsible for the infection prevention and control program and had received specialty training. The ADON LVN IPCP E stated she was trained that a sterile field must remain in front of the staff using it. She stated staff must not turn away from the sterile field. ADON LVN IPCP E stated she expected staff to disinfect surfaces prior to setting supplies down on it, especially when it is a sterile procedure. She stated not disinfecting the surface prior to performing tracheostomy care or turning away from a sterile field could introduce bacteria into a resident's respiratory system if done while performing tracheostomy care. During an interview on 04/10/2026 at 04:42 PM, the Director of Nurses stated she had worked at the facility for about 5 years. She stated she expected staff to follow policy and procedure when performing tracheostomy care to a resident. She stated that staff turning their back to the sterile field was not following policy. The Director of Nurses stated a sterile field needed to be always monitored to ensure it remains sterile. She stated if the sterile field is contaminated, then a resident could get an infection. During an interview on 04/10/2026 at 04:50 PM, the Administrator stated she expected staff to follow all infection control protocols when performing tracheostomy care. She stated she did not consider staff turning their back to a sterile field following infection control protocol. She stated staff turning their back to the sterile field could expose a resident to a contaminated source. Review of undated facility policy titled Tracheostomy Care Procedure reflected: Policy:Tracheostomy care will be performed per physician's order. Tracheostomy care is a procedure designed to maintain a patient airway and a sterile/clean area in and around a patient's tracheostomy. This procedure is performed using aseptic [sterile] technique at least every twelve (12) hours and as needed. When the tracheostomy tube holder is changed (usually once per day), the procedure requires two (2) people. Procedure:.4. Wash hands and observe universal precautions.

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food in accordance with professional standards for 1 of 1 kitchen observed for food service safety.1. The facility failed to properly store, label and date all food items located in the walk-in refrigerator on 04/08/2026 and 04/10/2026.2. The facility failed to ensure the dry food pantry was clean and free of accumulated black residue on the wall and shelves.These failures could have placed residents at risk for food contamination and foodborne illness.Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food in accordance with professional standards for 1 of 1 kitchen observed for food service safety.1. The facility failed to properly store, label and date all food items located in the walk-in refrigerator on 04/08/2026 and 04/10/2026.2. The facility failed to ensure the dry food pantry was clean and free of accumulated black residue on the wall and shelves.These failures could have placed residents at risk for food contamination and foodborne illness.Findings included:Observation during the initial tour of the kitchen on 4/08/2026 beginning at 9:07 AM, the following was observed in the walk-in refrigerator: 1 storage bag filled with slices of bread, crackers, cookies, pudding, and one other item unlabeled; the storage bag was labeled lunch bag with 4/5 date, no use by/discard date. Storage bag with several disposable cups of tartar sauce with a prep date of 3/27, no use by/discard date. 1 container with 3 prepared hamburger patties with melted cheese on top with prep date of 4/7 with use by date of 4/17(10 days later) 1 container of leftover gravy with a prep date of 5/6 and use by date of 5/11/2026 in the month of April.During a follow-up tour of kitchen of the dry food pantry area on 04/09/2026 beginning at 9:58AM, revealed a large area behind the food storage racks on the wall contained a black substance that resembled mold. The substance was also observed on the bottom shelf of the storage rack, and on the floor in dry food storage area.During tour of kitchen on 04/10/2026 beginning at 10:40 AM revealed a plastic storage container of individually packaged sandwiches (5 with meat, 1 with jelly/peanut butter), the sandwiches did not include labels with name, date, and discard date.Interview conducted on 04/10/2026 at 11:31 AM, [NAME] A stated she had worked for the company for 20 years but now she only worked PRN. [NAME] A stated that all dietary staff were responsible for labeling and dating food items. [NAME] A reported that all items must be labeled with an open and a discard date. [NAME] A stated that cooked foods are kept for a maximum of seven days, while dry food items vary depending on the specific product. [NAME] A stated that all staff were responsible for cleaning the dry food storage area, including the walls. [NAME] A stated that the spots observed on the wall looked like mold to her, she stated that maintenance cleaned the area earlier that morning. [NAME] A stated that the potential risk to residents, if the substance was mold, could be serious, including illness or possible death. [NAME] A reported that the process was to notify the manager immediately when any unknown or concerning substance is identified on surfaces.Interview conducted 04/10/2026 at 11:41 AM, the DMA stated she had been with the facility for a year. She stated that food items should be properly labeled and dated, including the product name, date opened, and a discard date of seven days. The DMA reported that food prepared in-house was to be used within seven days in accordance with facility policy. The DMA stated that the department followed a daily and weekly cleaning schedule. She reported that dry storage area shelves are cleaned approximately once per month. The DMA stated that the black substance observed on the wall in the dry storage area had been previously reported and that efforts had been made to resolve the issue. She reported she was not informed of the exact nature of the substance but stated that maintenance had been addressing it. The DMA stated the area was first treated back in June 2025, at which time a portion of the wall was removed; however, the substance has since reappeared. The DMA stated that the potential risk to residents included cross-contamination related to the presence of the substance.Interview conducted 04/10/2026 at 5:03 PM, the Maintenance Supervisor stated that an unknown substance had previously been present on the kitchen wall and that previous contractors had repaired a hole in the wall at that time. He reported that the cooler located next to the dry storage area does not always close properly due to worn door gaskets, resulting in an improper seal.The Maintenance Supervisor stated that condensation formed because the adjacent area was warmer, which may have contributed to the issue. He reported that a replacement door has been ordered from the manufacturer in [city] and was expected to be installed soon. He stated the new door will fix the issue. The Maintenance Supervisor stated that the potential risk associated with the substance is that it could cause illness if exposure occurred.Review of the facility's policy named Food Storage and Supplies dated 2012, revealed: Procedure:All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin and insects.9. Perishable items that are refrigerated are dated once opened and used within 7 days.Review of the facility's policy named Left -Over Foods, dated 2012 reflected: Left -over foods shall be handled in a manner to ensure the safe use of these foods at a later date.Procedure:1. Left-over foods shall be refrigerated, dated, labeled, and properly covered after meal service.A record review of the FDA's 2022 Food Code reflected the following:2. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.3. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

Based on observations, interviews, and reviews, the facility failed to provide food that was prepared in a form designed to meet individual needs and by methods that conserve nutritive value and flavor for 4 residents who ate pureed diets from 1 of 1 kitchen reviewed for food and nutrition services.The facility failed to ensure that the lunch meal on 04/09/2026 was served at the correct temperature and was palatable. The facility failed to ensure [NAME] A refrained from adding an unmeasured amount of liquid to fish sticks, pureed meal during lunch service on 4/10/2026. This failure could affect residents at risk for diminished or altered nutritional status and potential weight loss.Email received from the Administrator on 04/09/2026 at 8:23 revealed 4 residents at the facility received a pureed diet. Observation and interview conducted on 04/10/2026 at 10:43 AM revealed [NAME] A placed an unmeasured amount of broth into the puree blender with the fish sticks. She did not measure the broth. [NAME] A proceeded to puree the fish sticks. She stated there were 4 residents on puree diets. [NAME] A stated that pureed food was supposed to be of creamy texture. The pureed fish was of a runny consistency. She stated she had a measuring cup available but did not use it. [NAME] A stated she has prepared pureed diets for over 10 years. The DMA interjected and stated to [NAME] A the texture should be of mashed potato consistency. [NAME] and surveyor went over to the recipe book, the recipe called for a half of cup of broth for 4 servings, it stated to add one half of recommended liquid and puree. The recipe stated to add bread if needed and blend until smooth, adding liquid/thickener as necessary to obtain desired consistency. [NAME] A then added bread to the mixture until it had corrected consistency.Interview conducted on 04/10/2026 at 11:31 AM [NAME] A revealed she has worked for the company for 20 years but now she only worked PRN. She stated she had been trained on pureed diets by previous dietary managers. [NAME] A admitted that because she had done it for so long, she had relied on her own judgement to decide if the food texture was correct. She stated she became nervous when state inspectors are present. [NAME] A stated if food was not the correct consistency, a resident could possibly choke. Interview conducted on 04/10/2026 at 11:41 AM, the DMA stated she had been with the facility for a year. She stated all the cooks had their dietary certificates. The DMA stated some of the cooks were trained by previous dietary managers. She stated she provided ongoing in-service education to the dietary staff. The DMA stated she observed cooks during food preparation and has provided guidance on proper procedures that included standardized recipes and the pureed diet spreadsheets. The DMA stated following the prescribed therapeutic diets ensured safety. She reported that she conducted routine rounds on the tray line to monitor and verify correct food consistency. The DMA stated the potential harm to a resident was increased risk of aspiration if pureed diet was not followed. Interview via telephone conducted on 04/10/2026 at 4:26 PM, the Dietician Consultant stated the DMA trained the cooks on the pureed diet process. She stated she comes to the facility once month. Dietician Consultant stated she looks at the consistency and check off on the textures of the food to ensure compliance with the prescribed diet. She stated all cooks should follow the recipe book. Dietician Consultant stated, not following the pureed recipe could be a potential for swallowing issues, but that would be a speech area. Interview conducted 04/10/2026 at 4:48 PM, the DON stated physician-ordered diets (such as pureed diets) are communicated to nursing and dietary staff. The DON stated the nurses check the trays prior to them being served to the residents. She stated that the diet order was on the meal ticket and nurses are trained to review the tickets. The DON stated that if there was a concern regarding the meals staff are supposed to report her or the DMA. The DON stated pureed consistency should not be runny but solid resembling a baby food consistency. The DON stated that potential harm to a resident would be the risk of aspiration if the food is runny or potential harm of choking if food is too thick.Review of the facility's policy named Consistency Modification, dated 2012, reflected: Procedure:We will adequately meet nutritional needs of the resident and provide food in a consistency that the resident can tolerate.3. The pureed diet is given to residents with chewing, swallowing or choking problems.The desired consistency for blended foods is that of applesauce to mashed potatoes. Small grains may be present in some foods, but these are acceptable as long as they are no larger than the grains present in applesauce and of a consistent size. If a residentrequires a smoother consistency, per speech therapist recommendation, an order for a strained puree diet can be obtained. Guidelines for pureed diets:1. Eye appeal is important. Items are served attractively on the plate with appropriate garnishes. 2. Sauces and gravies are used to improve flavor and ease of eating.3. Foods are blended following the regular diet for the day.4. When therapeutic diets are blended, the menu for the day, diet and portion are used.5. Proper holding and serving temperatures are observed.

Based on observation, interview, and record review the facility failed to maintain medical records in accordance with accepted professional standards and practices that are completely and accurately documented for 1 (Resident #26) of 7 residents reviewed for medical records. The facility failed to maintain complete and accurate documentation of provided incontinent care for Resident #26. This deficient practice could place residents at risk for not receiving proper care due to incomplete and inaccurate records.The findings include: During an attempted interview with Resident #26 on 4/09/2026 at 2:15 p pm. to verify if he was changed or needed to be changed, he was unable to give comprehensive answer regarding his incontinent status. Record review of Resident #26's face sheet, dated 04/10/2026, reflected [AGE] year-old male originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included: unspecified convulsions (sudden, involuntary, and often violent contractions of muscles, characterized by shaking, rigidity, and potential loss of consciousness), major depressive disorder severe with psychotic symptoms (a serious, common mental health condition characterized by persistent sadness, loss of interest, and low energy), and schizophrenia (a chronic, severe brain disorder causing distorted interpretations of reality, including hallucinations, delusions, and disorganized thinking). Record review of Resident #26's quarterly MDS assessment, dated 03/25/2026, with a level 3 for cognitive skills for daily decision making indicating the severely impaired - never/rarely made decisions. Resident #26's MDS indicated his total dependance on helper for all efforts or the assistance of 2 or more helpers is required for the resident complete eating, oral hygiene, toileting hygiene, shower/bath and dressing. Record review of Resident #26's comprehensive care plan, dated 09/12/2025, indicated a focus: ADL Self CarePerformance Deficit and bowel and bladder incontinence and indicated interventions in place: Check resident every two hours and assist with toileting as needed and provide peri care after each incontinent episode. Review of POC record in electronic resident record revealed in last 14 days there was a lack of documentation for Resident #26'sincontinent care: *03/27/2026 - one time at 3:52 p.m., *r45fvg03/28/2026 - one time at 1:59 p.m., *03/29/2026 - one time at 2:23 a.m., *03/30/2026 - two times at 1:45 a.m. and 9:17 a.m., on *04/03/2026 - two times at 9:56 and 18:56, on *04/04/2026 - two times at 2:37 a.m. and 9:36 p.m., and *04/08/2026 - 2 times at 9:02 a.m. and 2:36 p.m. During interview with DON on 4/10/2026 at 8:45 a.m. she stated that CNAs responsible for documentation of incontinent care every shift (8hours) which would be three entries for each day. She stated that per facility policy nursing staff was not required to document Resident #26 did not require incontinent care due to being dry. She stated that not documenting incontinent care for residents required incontinent care and, Resident #26 specifically, was not acceptable documentation practice. She stated that not documenting incontinent care could cause not able to track urine retention pattern or other nursing concerns including not providing proper care for residents. She stated that facility established a routine peri care rounding for Resident #26 when staff can document rounds every hour in the paper finder available at the nursing station due to POC allowing to document incontinent care only one per shift (8 hours). She stated that CNAs could inform charge nurses regarding additional incontinent care for residents if they did more than one time per shift and charge nurse could document it in nursing notes. During an interview on 4/10/2026 at 9:01 a.m., ADM stated per facility's policy CNAs were responsible for accurate and consistent documentation in POC with daily monitoring of this documentation by nursing management. Management team (DON and ADON) were required to meet and educate CNAs if incontinent care was not documented once a shift. She stated that not documenting incontinent care every shift in POC can lead to miscommunication of abnormal findings. She stated that Resident #26 required every two hours rounding, with documentation in POC and paper log available at the nursing station. She stated that she was ultimately responsible for overseeing the completed documentation at the facility. Record review of nursing notes for Resident #26 for the last 6 months (09/12/2026 -04/08/2026) did not reflect nursing notes regarding provided incontinent care for Resident #26 on those days. Record review of in-services dated 1/20/2026 revealed Please completed all POC (plan of care) documentation before you leave. Be sure bowel and bladder and locomotion is accurate. When documenting, make sure you are taking your time and documenting correctly on locomotion and bowel and bladder. Record review of Resident #26's Q1 hour checks paper record revealed The following items will be checked every hour: 1. Call light and personal items (e.g., remote, water in easy reach) . positioned with pillows. check for incontinence and assist with clean up as needed. Weekly pages of Resident #26's revealed multiple gaps in documentation of care for Resident #26.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident #26) of 7 residents reviewed for resident rights. The facility failed to encourage and assist Resident #26 with dressing in his preferred personal clothing which was available on-site rather than hospital type gowns during the day. This failure could place residents at risk for diminished quality of life, loss of dignity, and a decrease sense of self-worth. The findings include: Record review of Resident #26's face sheet, dated 04/10/2026, reflected [AGE] year-old male originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included: unspecified convulsions (sudden, involuntary, and often violent contractions of muscles, characterized by shaking, rigidity, and potential loss of consciousness), major depressive disorder severe with psychotic symptoms (a serious, common mental health condition characterized by persistent sadness, loss of interest, and low energy), and schizophrenia (a chronic, severe brain disorder causing distorted interpretations of reality, including hallucinations, delusions, and disorganized thinking). Record review of Resident #26's quarterly MDS assessment, dated 03/25/2026, with a level 3 for cognitive skills for daily decision making indicating the severely impaired - never/rarely made decisions. Resident #26's MDS indicated his total dependance on helper for all efforts or the assistance of 2 or more helpers is required for the resident complete eating, oral hygiene, toileting hygiene, shower/bath and dressing. Record review of Resident #26's comprehensive care plan, dated 09/12/2025, reflected a focus on ADL Self CarePerformance Deficit and indicated interventions: Dressing: Assist the resident to choose simple comfortable clothing thatmaximizes the president's ability to dress self. Monitor for escalating anxiety, depression or and report immediately to the nurse. Observation of Resident #26 on 04/08/2026 at 09:30 a.m. reflected Resident #26 was wearing hospital gowns during the day between 8 a.m. and 5 p.m. on all three days while he was out of his room watching TV in the common area, therapy sessions and eating meals in the dining room. Nursing staff provided Resident #26 with showers and dressed him in clean hospital gowns and not his personal clothing that was available in his room. Observation of Resident #26 on 04/09/2026 at 11:30 a.m., reflected Resident #26 was wearing hospital gowns during the day between 8 a.m. and 5 p.m. on all three days while he was out of his room watching TV in the common area, therapy sessions and eating meals in the dining room. Nursing staff provided Resident #26 with showers and dressed him in clean hospital gowns and not his personal clothing that was available in his room. Observation of Resident #26 on 04/09/2026 at 1:30 p.m. reflected Resident #26 was wearing hospital gowns during the day between 8 a.m. and 5 p.m. on all three days while he was out of his room watching TV in the common area and eating meals in the dining room. Nursing staff provided Resident #26 with showers and dressed him in clean hospital gowns and not his personal clothing that was available in his room. Observation of Resident #26's closet on 04/09/2026 at 2:21 p.m., revealed a variety of clothing items available in Resident #26's closet. The sign on Resident #26's closet indicated that family was doing his laundry. The laundry hamper was empty at that time. During an interview on 04/08/26 at 11:05 a.m. with RN C during Resident #26's peri care, she stated that to her knowledge this resident did not have personal clothes in his room. During an interview on 04/09/2026 at 1:05 p.m. with CNA P she stated this resident had clothes in his room and she put a hospital gown just because it was easier to put it on in the morning. During interview on 04/09/2026 at 2:05 p.m., Resident #26's family member stated that she washes his clothes on regular basis and Resident #26 had plenty of different clothes to choose from in his room. She stated that Resident #26 liked wearing regular clothes and preferred wearing regular clothes and not a hospital gown. She stated that not wearing regular clothes affected Resident #26's feelings about himself. During an attempted interview with Resident #26 on 4/09/2026 at 2:15 p pm. to identify his preference of clothes, he was unable to give comprehensive answer regarding him wearing hospital gown during the day. During an interview on 04/10/2026 at 2:15 p.m., ADON LFN F stated that Resident #26 does not always have clean clothes available in his room as his family member does the laundry and do not bring the clean clothes back to the facility. She stated that staff must put personal clothes on Resident #26 when it was available and she was responsible for overseeing nursing staff assisting residents with wearing their personal clothing. She stated that she was aware of Resident #26's RP wanted him to wear his own clothes and not a hospital gown. She stated that wearing clothes of choice was Resident #26's right. During an interview on 04/10/2026 at 9:01 a.m., DON stated that staff should assist residents in dressing in their own clothes including Resident #26 who should be dressed in his own clothes if it's available. She stated that wearing hospital gown during the day was not acceptable if Resident #26 or his RP indicated their preference for wearing personal clothes as all residents have a right to choose their own clothes. During an interview on 04/10/2026 at 9:53 AM, ADM stated that residents have a right to choose their own clothing and staff should provide them with this choice. She stated that Resident #26 should be wearing his own clothes if he has them available. She stated that wearing hospital gown during the day could affect residents' dignity in general. During interview on 04/10/2026 11:26 a.m., The Area Director of Operations stated that residents have a right to choose their own clothes to dress and wearing a hospital gown could affect their dignity. She stated that she heard that Resident #26 resisted staff assisting him with wearing his clothing, but after verifying with nursing staff on 04/10/2026, she stated that staff informed her Resident #26 did not indicate resistance to dressing provided by staff at this time. Review of facility's undated policy Resident Rights revealed residents have the right to retain and use personal possessions, including.clothing. Review of facility's undated policy Dressing and Personal Grooming revealed: The purpose of this procedure are to assist the resident as necessary with dressing and undressing. to encourage the resident to choose the clothes that he or she will wear for that day. Dress the resident in his or her own clothing.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 15 residents (Resident #10) reviewed for resident rights.The facility failed to ensure Resident #10's bathroom was free from dirt on the floor.This failure could place residents at risk of infection and diminished quality of life.Findings include:Record review of Resident #10's admission record, dated 04/10/2026, reflected a [AGE] year-old female admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that included urinary tract infection, depression (a mood disorder with persistent feeling of sadness and loss of interest), and chronic kidney disease (the gradual loss of kidney function).Record review of Resident #10's Quarterly MDS, dated [DATE] reflected a BIMS score of 13, which indicated no cognitive impairment.During an interview and observation on 04/08/2026 at 1:55 PM, Resident #10 stated it made her upset that the facility did not clean her bathroom appropriately on a daily basis. She stated there was a dirt ring around the perimeter of the bathroom floor in her room and she escorted this investigator to the bathroom in question. She stated the staff did not sweep before they mopped in her bathroom. Observation revealed a dark colored dirt/dried mud like substance with debris around the perimeter of the bathroom. During an observation on 04/10/2026 at 9:04 AM, Resident #33's bathroom floor revealed a dark colored dirt/dried mud like substance with debris around the perimeter of the bathroom.During an interview on 04/10/2026 at 12:03 PM, the ADON LVN IPCP E stated she expected resident's rooms, including bathrooms, to be swept and mopped daily. The ADON LVN IPCP E reviewed pictures of Resident #33's bathroom and stated she did not consider the pictures to reflect a clean floor. She stated a resident could get sick if their room/bathroom is not cleaned regularly and if they had an open area then germs could cause an infection.During an interview on 04/10/2026 at 03:59 PM, the housekeeping manager stated she had received training from corporate on how to manage the housekeeping department. She stated she expected her staff to sweep first then mop, including all the corners, of resident's rooms every day. After reviewing the pictures of Resident #33's bathroom floor, she stated she did not consider that to be clean. The housekeeping manager stated if a resident's room was not cleaned appropriately, then if they have an allergy to dust or dirt it can trigger the allergy. She stated the smell could affect the resident or even make the resident sad or depressed.During an interview on 04/10/2026 at 04:42 PM, the Director of Nurses stated she expected housekeeping to keep rooms clean, so the facility can provide the residents with a home-like environment. After reviewing the pictures of Resident #33's bathroom floor, the Director of Nurses stated, that is not a clean environment. She stated a resident could get sick if their environment was not kept clean.During an interview on 04/10/2026 at 04:50 PM, the Administrator stated she expected staff to sweep and mop the Resident's rooms and bathrooms daily. After reviewing the pictures of Resident #33's bathroom floor, the Administrator stated the pictures did not meet her expectations. She stated if the residents' rooms were not cleaned appropriately, then it could expose the residents to an unclean surface and potential infection.Review of undated facility policy titled Resident Rights reflected The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy.A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.Self-Determination - The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice.11. The facility must not impose a charge against the personal funds of a resident for any item or service for which payment is made under Medicaid or Medicare (except for applicable deductible and coinsurance amounts). The facility may charge the resident for requested services that are more expensive than or in excess of covered services.a. Services included in Medicare or Medicaid payment. During the course of a covered Medicare or Medicaid stay, facilities must not charge a resident for the following categories of items and services: .iv. Room/bed maintenance services.

Based on interviews and record reviews the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 ( Resident #22 and Resident #52) out of 8 residents reviewed for care plans. The facility failed to update the comprehensive care plan to reflect Resident #22 and Resident #52 received in room activity programs. This failure could have placed residents at risk for not having their needs identified and met. Findings include: Record review of Resident #22's face sheet, dated 04/09/2026, reflected a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety ( a medical diagnosis indicating that a person has a clear memory loss and the specific cause and severity have not been determined and does not have any behaviors associated with unspecified dementia), cognitive communication deficit ( a communication impairment caused by underlying disruptions such as memory and attention deficit rather than primary speech or language problems), and lack of coordination ( the inability to control voluntary muscle movements, resulting in jerky, unsteady, or clumsy motion). Record review of Resident #22's Annual MDS Assessment, dated 01/15/2026 reflected Resident #22 had a BIMS score of 15 indicating her cognition was intact. Resident #22's activity preferences were the following: participate in favorite activities and keep up with the news. Record review of Resident #22's Comprehensive Care Plan, dated 01/26/2026, reflected Resident #22's activity care plan was not revised to meet his current activity preferences. Record review of Resident #52's face sheet, dated 04/09/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of unspecified dementia, unspecified severity, without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety ( a medical diagnosis indicating that a person has a clear memory loss and the specific cause and severity have not been determined and does not have any behaviors associated with unspecified dementia), contracture left and right hand ( a common, progressive hand deformity where tissues under the palm skin thicken, forming cords that pull one or more fingers into a permanently bent position), limitation of activities due to disability (a reduction in a person's ability to perform tasks due to physical impairment), and hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side ( paralysis on the left side of the body due to tissue damage to the brain or spinal cord). Record review of Resident #52's Annual MDS Assessment, dated 06/30/2025 reflected Resident #52 had a BIMS score of 7 indicating his cognition was severely impaired. Resident #52 enjoyed participating in his favorite activities ( does not specify his favorite activities). Record review of Resident#52's Quarterly MDS Assessment, dated 3/11/2026, reflected Resident #52 had a BIMS score of 7 indicating his cognition was severely impaired. Record review of Resident #52's Comprehensive Care Plan, dated 04/07/2026, reflected Resident #52's activity care plan was not revised to meet his current activity preferences. Record review of Resident #22 and Resident #52's Activity Participation records reflected they were to receive in room activities in January 2026, February 2026, March 2026 , and April 2026. Interview on 04/08/2026 at 3:00 pm The Activity Director stated Resident #22 and Resident #52 were on in room activity programs. She stated they did not prefer to attend group activities. She stated anytime there was a change in the resident's activity preferences she was expected to revise the care plan. The Activity Director stated Resident #22 and Resident #52's care plan was recently updated sometime in January or February 2026. She stated in-room activities needed to be added to Resident #22 and Resident #52's care plan. She stated if Resident #22 and Resident #52 were having any type of behaviors or felt lonely the staff would not know their activity plan if it was not revised to their current preferences. She stated with Resident #22 and Resident #52's care plan not revised, and this could affect them not having their needs met by staff. She stated it was her responsibility to revise any care plan related to activities. The Activity Director stated in-room activities were not on Resident #22 and Resident #52's current activity care plan. Interview on 04/10/2026 at 9:52 am The Director of Nurses stated anytime a resident's activity preference changed the care plan was expected to be revised. She stated if a resident preferred in room activities the other staff needed to know this information to prevent him from becoming frustrated when staff may invite him to activity programs. The Director of Nurses stated the Activity Director was responsible for discussing the changes in the care plan with the interdisciplinary team and making the revision on the care plan. Interview on 04/10/2026 at 2:30 pm the MDS Coordinator LVN stated if a resident had a change in their activity preference the activity care plan was expected to be revised. She stated the Activity Director was expected to discuss the changes with the interdisciplinary team. The MDS Coordinator, LVN was responsible to make the revision to the care plan. She stated it was very important to revise any changes with the resident to the care plan. She stated the staff would not know what type of care or activities to do with the resident if the care plan was not updated to meet their current needs and preferences. She stated in-room activities were not on Resident #22 or Resident #52's current care plan. Record review of the facility's undated policy titled Comprehensive Care Planning reflected The resident's preferences and goals may change throughout their stay, so facilities should have an ongoing discussion with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical physical, mental and psychosocial needs.

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident # 22 and Resident #52) reviewed for ADL care.The facility failed to ensure Resident #22 and Resident #52's nails were cleaned and did not have any on 04/08/2026 and 04/09/2026. This failure could place residents at risk of not receiving services or care, diminished quality of life , and decreased self-esteem.Findings included: Record review of Resident #22's face sheet, dated 04/09/2026, reflected a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety ( a medical diagnosis indicating that a person has a clear memory loss and the specific cause and severity have not been determined and does not have any behaviors associated with unspecified dementia), type 2 diabetes mellitus without complications ( a person's body cannot use insulin properly and/or does not make enough insulin. This leads to high blood sugar. Person does not have any physical complications related to diabetes), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side ( paralysis on the right side of the body due to tissue damage to the brain or spinal cord), and lack of coordination ( the inability to control voluntary muscle movements, resulting in jerky, unsteady, or clumsy motion). ) Record review of Resident #22's Annual MDS Assessment, dated 01/15/2026 reflected Resident #22 had a BIMS score of 15 indicated cognition was intact. Resident #22 required supervision or touching assistance with the following ADLS:Personal hygieneToileting hygieneShowersLower body dressingTransfersBed mobility Record review of Resident #22's Comprehensive Care Plan, dated 01/26/2026, reflected Resident # 22 had ADL self-care performance deficit. Interventions: Assist Resident #22 with personal hygiene. Bathing: Check Resident #22's nail length, trim and clean on bath day and as needed. Observation and interview on 04/08/2026 at 10:00 a.m. revealed Resident #22 was lying on his bed. Resident #22's fingernails on his right hand underneath his forefinger, middle, ring fingernails had a blackish/brownish substance. He had blackish/brownish substance underneath his ring, middle and fore fingernails on his left hand. He stated he asked someone Saturday (04/03/2026) to clean his nails and the person stated they would get someone to clean them on Sunday (04/04/2026). He stated no one came to his room to clean his nails on Sunday. Resident #22 stated he did not recall the staff name. He stated she worked with the nurses.Record review of Resident #52's face sheet, dated 04/09/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of unspecified dementia, unspecified severity, without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety ( a medical diagnosis indicating that a person has a clear memory loss and the specific cause and severity have not been determined and does not have any behaviors associated with unspecified dementia), contracture left and right hand ( a common, progressive hand deformity where tissues under the palm skin thicken, forming cords that pull one or more fingers into a permanently bent position), limitation of activities due to disability (a reduction in a person's ability to perform tasks due to physical impairment), and hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side ( paralysis on the left side of the body due to tissue damage to the brain or spinal cord).Record review of Resident #52's Quarterly MDS Assessment, dated 03/11/2026, reflected Resident #52 had a BIMS score of 7 indicating his cognition was severely impaired. Resident #52 was dependent on staff for the following:Personal hygieneUpper and lower body dressingShowersToileting hygieneShower transfersRecord review of Resident #52's Comprehensive Care Plan, dated 04/07/2026, reflected Resident #52 had an ADL self-care performance deficit. Intervention: Bathing: Resident #52 required assistance by staff with bathing. During bathing check nail length, trim nails, clean nails, and as needed. Assist Resident #52 requires assistance with personal hygiene.Observation and interview on 04/09/2026 at 10:30 am revealed Resident # 52 was lying in his bed located in his room. Resident #52's fingernails on his left and right hand underneath his middle and ring fingernails had a blackish/brownish substance. Resident #52 did not want to answer any questions.In an interview on 04/10/26 at 8:02 am, the Administrator stated if a resident ingested the blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria, however it would be difficult to determine if the blackish/ brownish substance was bacteria. She stated it was a possibility a resident may become ill with stomach issues such as vomiting and nausea if they ingested the blackish/ brownish substance. She stated the Nurses were responsible for diabetic residents' nails such as cleaning, trimming, and filing. She stated the CNAs were responsible for nail care on all other residents. She stated nail care was completed on shower days, Sundays and as needed. She stated the ADON and DON were responsible for monitoring ADL care which included nail care. The Administrator stated anyone who observed Residents needing any type of nail care was instructed to report to the nurse. She stated an in-service had been given to the staff on nail care. The Administrator stated she did not recall the date. In an interview on 04/10/2026 at 10:20 am, RN L stated the nurses were responsible for all residents' with diagnosis of diabetes nail care such as trimming, cleaning, and filing. She stated the CNAs were responsible for all other residents' nail care. She stated nail care was usually completed on Sundays, as needed and during showers. RN L stated if a resident had brownish/blackish substance underneath their nails and if a resident swallowed the substance there was a possibility a resident may become ill, such as an infection in the stomach. She stated there was a possibility a resident may have nausea and vomiting. RN L stated if a resident refuses showers, nail care or any type of care the nurses document in the nurse's progress notes. She stated she was not aware of Resident # 22 and Resident #52 refusing nail care. RN L stated she had been in-serviced on nail care, and all staff was to report any nail issues with the resident to the nurse.In an interview on 04/10/2026 at 10:40 am, CNA M stated the nurses were responsible for diabetic nail care. She stated if a CNA observed any problems with a resident's nails the CNA was to report it to the nurse supervisor with any resident. CNA M stated the CNAs complete all nail care for residents without a diabetes diagnosis. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill, such as nausea and diarrhea. CNA M stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. CNA M stated anytime a resident refused any type of care she reported it to the charge nurse and the charge nurse would document it in the resident's medical record. She stated she was not aware of Resident # 22 or Resident #52 refusing nail care. She stated she had been in-service on nail care; however, she did not recall the date.In an interview on 04/10/2026 at 10:55 am, RN B stated the CNAs were responsible to clean and trim all residents' nails except for the residents with diabetes. She stated the nurses were responsible for nail care for diabetic residents. RN B stated the residents' nails were usually cleaned during shower days and on Sundays. She stated she was not an expert on bacteria and could not answer the question if a resident ingested blackish/brownish substance. RN B stated an upper GI doctor would need to respond to that question. She stated how was she to know what may happen to a resident if they ingested feces. She stated this was not in her scope of knowledge on feces or bacteria. RN B refused to respond to any further questions. Record review of the facility's policy on Nail Care, not dated, reflected Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle care and is usually done during the bath. Nails can become thinner and more brittle in the elderly and thicker if peripheral circulation is impaired. Nails are also important in assessment, as changes occur with certain medical conditions, such as clubbing with chronic obstructive pulmonary disease or cardiac disease. Color changes with circulatory or lymphatic impairment and certain drug therapy is common. Ingrown toenails are also common in the elderly. Fungal infections of the toenails, dry, brittle ridges and thickening of the nails all occur in the elderly with some frequency.Goals1. Nail care will be performed regularly and safely.2. The resident will be free from abnormal nail conditions3. The resident will be free from infection. ProcedureShould be performed according to the resident centered plan of care.1. Explain the procedure to the resident.2. Wash hands.3. Immerse hands or feet in a basin of warm soapy water to cleanse and soften the nails for ease incleansing and trimming. Use a soft brush if necessary to cleanse under and around the nails.4. Remove debris from under the nails with an orange stick while soaking.5. Remove the hands or feet from the basin and pat dry.6. Apply lotion and massage into the cuticles and push back with a towel. Avoid cutting anycuticle.7. Trim the nails with a clipper, straight across for the toenails and rounded for the fingernails.8. Smooth the nails with an emery board.9. Apply hose and shoes or slippers as appropriate.10. Discard removed nails, cleanse basin and articles used and store for future use.11. Wash hands.12. Nails that are ingrown, thickened, or infected should be cared for by a podiatrist. Reportconditions immediately to the primary nurse. The nurse will ensure a referral to the podiatrist.13. Cutting should not be any shorter than at the line even with the nail folds on each side.14. When performed at bath time, the nail care can be done following the procedure or as a separateprocedure when needed at the convenience of the resident.

Based on interview and record review, the facility failed to provide an ongoing activity program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 2 (Residents #22, and #52 of 6 residents reviewed for activities. The facility failed to provide activities for Resident #22 and Resident #52 to meet their psycho-social and mental needs for the months of January, February , March and April 2026.This failure could place residents at risks of boredom, depression, behavior, diminished quality of life and decreased cognitive function. Findings include:Record review of Resident #22's face sheet, dated 04/09/2026, reflected a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a medical diagnosis indicating that a person has a clear memory loss and the specific cause and severity have not been determined and does not have any behaviors associated with unspecified dementia), cognitive communication deficit (a communication impairment caused by underlying disruptions such as memory and attention deficit rather than primary speech or language problems), and lack of coordination (the inability to control voluntary muscle movements, resulting in jerky, unsteady, or clumsy motion). Record review of Resident #22's Annual MDS Assessment, dated 01/15/2026 reflected Resident #22 had a BIMS score of 15 indicated cognition was intact. Resident #22's activity preferences were the following: participate in favorite activities and keep up with the news. Record review of Resident #22's Comprehensive Care Plan, dated 01/26/2026, reflected Resident #22's activity care plan was not revised to meet his current activity preferences. Record review of Resident #22's Activity Participation records reflected Resident #22 did not receive in-room activities during the months of January 2026, February 2026, March 2026, and April 2026. Observation and interview on 04/08/2026 at 10:00 a.m. revealed Resident #22 was lying on his bed. Resident #22 stated he did not enjoy going to group activities. He stated he preferred someone coming to his room and talking with him. Resident #22 stated he had not received any activity visits from anyone. He stated he remembered telling someone he wanted activities in his room few months ago, but he did not recall the person's name. Resident #22 stated he would go out of his room, but he enjoyed talking to people and wanted someone to come to his room and visit with him about 15 to 20 minutes about 4 days per week. He stated it did not need to be every day. Record review of Resident #52's face sheet, dated 04/09/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of unspecified dementia, unspecified severity, without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety ( a medical diagnosis indicating that a person has a clear memory loss and the specific cause and severity have not been determined and does not have any behaviors associated with unspecified dementia), contracture left and right hand ( a common, progressive hand deformity where tissues under the palm skin thicken, forming cords that pull one or more fingers into a permanently bent position), limitation of activities due to disability (a reduction in a person's ability to perform tasks due to physical impairment), and hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side ( paralysis on the left side of the body due to tissue damage to the brain or spinal cord).Record review of Resident #52's Annual MDS Assessment, dated 06/30/2025 reflected Resident #52 had a BIMS score of 7 indicating his cognition was severely impaired. Resident #52 enjoyed participating in his favorite activities (does not specify his favorite activities).Record review of Resident #52's Quarterly MDS Assessment, dated 3/11/2026, reflected Resident #52 had a BIMS score of 7 indicating his cognition was severely impaired.Record review of Resident #52's Comprehensive Care Plan, dated 01/26/2026, reflected Resident #52's activity care plan was not revised to meet his current activity needs. Record review of Resident #52's Activity Participation records reflected Resident #22 was to receive in-room activities. He did not receive in-room activities during the months of January 2026, February 2026, March 2026, and April 2026. Observation and interview on 04/09/2026 at 10:30 am revealed Resident # 52 was lying in his bed he did not have his television on and there was no stimulation in his room. Resident #52 stated no when attempted to ask him any questions.Interview on 04/08/2026 at 3:00 pm The Activity Director stated Resident #22 and Resident #52 were on in room activity programs. She stated both residents did not prefer to attend group activities. She stated she could not explain why Resident #22 and Resident #52 did not receive in-room activities. The Activity Director stated if a resident did not receive activities there was a possibility the resident may become depressed, isolate themselves in their room, not have any stimulation, have a decline in the mental status, and have a decline in their overall well-being. She stated all residents were expected to receive some type of activities. The Activity Director stated she had been working at the facility since August of 2025 and had her certificate of completing required activity courses. She stated she had worked as an activity assistant in a different city. She reviewed the participation records and agreed Resident #22 and Resident #52 did not receive in-room activities during January, February, March and April 2026. She stated both men (Resident # 22 and Resident #52) did not enjoy coming to activity programs outside of their room.Interview on 04/10/2026 at 11:45 a.m. the Administrator stated she expected a variety of activities to be provided for all residents. She stated each resident's activity preference needed to be assessed, and each resident's activity was expected to be planned according to their activity preferences. She stated activities such as independent, in-room, and/or group activities were to be documented on participation records. The Administrator stated she expected all residents to be interviewed, and their activity preferences updated and all care plans to be revised to reflect each resident's activity preferences. She stated if a resident was not receiving activities there was potential a resident would have a decline in their cognition, mental status, physical status and quality of life. She stated a resident with a history of depression may become depressed and isolate themselves in their rooms. The Administrator stated the Activity Director and Activity Assistant were responsible for the activity programming and documentation of all activities department including participation records. She stated she was the Activity Director's supervisor. Record review of the Activity Director's personnel file reflected Activity Director had a National Certification Council for Activity Professionals certificate with expiration date of 09/01/2027.Record review of Activity Participation, group and in- room activities, dated 12/5/2025, reflected Activity Director received this in-service.Record review of the facility policy on Activity Programming, dated 2011, reflected The Activity Director and staff will provide for ongoing activity programs. Programs will be geared to maintain functional ADLS, provide social interaction and, as the same time, protect residents from environmental over stimulation. Those who cannot participate in group settings are provided with individual programming. Inability to participate could include those who refuse to participate in activities, those who are in isolation or physician ordered bed rest. Record review of the facility's policy on Activity Documentation- General Guidelines, dated 05/06/2025, reflected the following areas are considered documentation responsibilities of the Activity Director and staff and should be completed in a comprehensive and timely manner such as: Resident Participation Records.

Based on observation, interviews, and record reviews the facility failed to ensure the resident environment remained as free of accident hazards as is possible for one of three housekeeping carts (Housekeeping Cart #1) reviewed for hazards.The facility failed to ensure Housekeeping Cart #1, with chemicals inside the compartments, was locked when unsupervised. This failure could place residents at risk for injuries, illness, and hospitalization.Findings included:Observation on 04/08/2026 at 9:15 am revealed Housekeeping Cart #1 was located near 100 hall. The compartment where chemicals were stored was not locked. The compartment had glass cleaner, disinfectant cleaner, tub and tile cleaner, and bio waste degrader. Housekeeper G was not standing near the housekeeping cart, and no other staff was near the unlocked housekeeping cart. Housekeeper G was at the end of 100 hall. There were not any residents near the unlocked housekeeping cart.During an interview on 04/08/2026 at 9:25 a.m., Housekeeper G stated the housekeeping cart was expected to be locked anytime housekeeper walked away from the cart. Housekeeper G stated she could not see Housekeeping Cart #1 from the 100 hallway. She stated there was a possibility that if a resident drank some of the chemicals the resident may become sick with stomach issues or have an allergic reaction. She stated it was possible a resident may need to be evaluated at the hospital. She stated she did have a key to the housekeeping cart, but it was difficult to lock the cart.Interview on 4/10/2026 at 8:05 a.m., the Administrator stated he expected the housekeeping cart to be locked at all times when the housekeeper was not obtaining an item from the housekeeping cart. The Administrator stated all housekeeping staff had been in-serviced on locking the housekeeping carts. She stated she checked with the nursing staff and there were not any residents who wandered on the 100 hall. The Administrator stated if a resident drank a chemical there was a possibility a resident may become ill with nausea and vomiting. She stated there was a possibility a resident may need to be transported to the emergency room for further evaluation. Interview on 04/10/2026 at 1:30 p.m., the Housekeeping Supervisor stated if a resident swallowed the chemical the nurse would not know what type of care to give the resident without knowing the name of the chemical. She stated all housekeeping carts were expected to be locked anytime the housekeeper was not standing in front of the cart. The Housekeeping Supervisor stated if a resident ingested some chemicals there was a potential for an allergic reaction, such as burning their throat, stomach and may need to be assessed at the hospital. She stated all housekeeping staff were in-serviced on locking housekeeping carts. She stated there was a possibility if a resident spilled chemical on their skin it may cause irritation to the skin. Review of the Facility's Daily Common Area Cleaning, dated 2026, reflected Housekeeping carts/chemicals must be locked when not within the eyesight of a staff member.

Based on interview, observation, and record review, the facility failed to ensure that a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 ( Resident #16) of three residents reviewed for catheter care. The facility failed to have the appropriate size foley catheter ( a medical device used to drain urine from the bladder) in the facility when Resident #16 was complaining of pain from his catheter on 04/08/2026.This failure could place residents at risk for infection, sepsis( a serious condition in which the body responds improperly to an infection, causing organ damage) and hospitalization.Findings included:Review of Resident #16's face sheet, dated 04/09/2026, reflected Resident #16 was a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications ( a diagnosis of diabetes where high blood sugar exists but had not caused chronic damage to organ systems), benign prostatic hyperplasia with lower urinary tract symptoms (a non-cancerous enlargement of the prostrate - a small gland in the male reproductive system- common in aging men, leading to lower urinary tract symptoms by compressing the urethra- a tube that connects the bladder to the outside of the body, allowing urine to be expelled. Symptoms include weak stream, hesitancy, frequency, urgency of urination), retention of urine (the inability to fully or partially empty the bladder, causing urine to remain in the bladder even after attempting to urinate), and obstructive and reflux uropathy ( a blockage in the urinary tract that hinders urine flow, causing backflow ( reflux) and kidney injury).Review of Resident #16's admission MDS Assessment, dated 02/04/2026, reflected Resident #16 had a BIMS score of 15 indicating his cognition was intact. Resident #16 had an indwelling catheter.Review of Resident #16's Comprehensive Care Plan dated 2/19/2026 reflected Resident #16 had an indwelling foley catheter. Interventions: Resident #16 had a 16 F 10 ml foley catheter. Position catheter bag and tubing below the level of the bladder in a privacy bag. Change the catheter as ordered. Monitor and document for pain or discomfort due to catheter. Monitor, record and report to MD( medical doctor) for signs and symptoms of UTI.Review of Resident #16's Physician Order dated 02/02/2026 reflected Resident #16 had an order for a foley catheter 16 F with 10 bulb- change for occlusion ( blockage , closure, or bringing together of two surfaces),leaking, closed system was compromised as needed. Pain medication was ordered on 04/08/2026 and started on 04/08/2026 at 5:30 pm.Review of the invoice on 04/08/2026 approximately 2:30 pm received from the Medical Record/ Central Supply Manager reflected the wrong size catheter was on the truck for Resident #16.Interview and observation on 04/08/2026 at 1:40 pm revealed Resident #16 was lying in bed and was moaning and had tears in his eyes. Resident #16 stated he was in pain with his catheter. He stated he had been in pain for the past few days. Resident #16 stated he did not report it to anyone until today (04/08/2026). He stated he did report his pain to an aide, and the nurse did come to his room and stated she would change his catheter. Resident #16 stated the nurse returned to his room and explained the facility did not have the size of catheter ordered for him but there was one on the delivery truck. He stated, I hope they hurry and get it changed soon. Resident #16 stated he had Tylenol ordered for pain, but it did not help.Interview on 04/08/2026 at 1:55 pm the Administrator stated she would email the invoice of the order delivered on 04/08/2026 to the facility from the medical supply company.Interview on 04/08/2026 at 2:00 pm LVN J stated she had checked with the Medical Record/Central Supply Manager and was informed she ordered Resident #16 a catheter and it was on the truck. LVN J stated the supply truck had been at the facility since around 12:00 pm today ( 04/08/2026). She stated she was waiting for the Medical Record/Central Supply Manager to find the catheter and bring it to her so she can change Resident #16's catheter. She stated Resident #16 did have Tylenol ordered for pain. LVN J stated she would call the physician and order him pain medication as needed. Interview on 04/08/2026 at 2:15 pm Resident #16 stated he felt better, and he was not in pain. He stated he did want his catheter changed sometime today 04/08/2026.Interview on 04/08/2026 at 2:30 pm LVN J stated she had not received the catheter from the supply truck. She stated she explained to Medical Record/ Central Supply Manager Resident #16 was needing the catheter. LVN J stated the Medical Record/ Central Supply Manager stated Resident #16's catheter was on the truck delivered today 04/08/2026. Interview on 04/08/2026 at 2:45 pm LVN J stated she had not received the catheter from the supply truck. She stated she had asked the Medical Record/ Central Supply Manager to locate the catheter for Resident #16. She stated she had not reported it to Director of Nurses.Interview on 04/08/2026 at 3:15 pm LVN J stated she had not received Resident #16's catheter from the supply truck.Interview on 04/08/2026 at 3:45 pm LVN J stated she had not received Resident #16's catheter from the supply truck.Interview on 04/08/2026 at 4:15 pm the Nurse Consultant stated someone was going to a sister facility in the same town and would obtain the catheter Resident #16 needed. She stated the wrong size catheter was delivered to the facility today ( 04/08/2026) and LVN J realized it was the wrong catheter size when it was given to her from the Central Supply Manager. The Nurse Consultant stated, I went to [Resident #16]'s room few minutes ago and adjusted his catheter until we can obtain the correct catheter from a sister facility.Interview on 04/09/2026 at 8:00 am Resident #16 stated the staff did change his catheter last night ( 04/08/2026). He stated the catheter was not working properly and the staff came back in and checked it and made adjustments to the catheter and when they made adjustments the urine began to flow better. He stated he was not in pain last night ( 04/08/2026) or today ( 04/09/2026).Interview on 04/09/2026 at 8:45 am The Medical Record / Central Supply Manager stated LVN K had come to her office and reported to her that Resident #16 needed a catheter and stated the catheter size was 22 F 10 ml foley catheter. She stated she placed an order on Thursday 04/02/2026. She stated this was the size catheter delivered yesterday on the supply truck and not the size catheter Resident #16 needed. She stated the supply truck did come in on 04/08/2026 approximately 12:00 pm. She stated she did not get the catheter off the truck until around 4:00 pm. The Medical Record/ Central Supply Manager stated LVN J did request for the catheter to be located for Resident #16. She stated she did not recall the time LVN K requested the catheter. The Medical Record/ Central Supply Manager stated she was trying to get all of the supplies off the truck and began delivering the supplies into the facility. She stated she did know LVN J was wanting a catheter, but she did not realize it was important. She stated she did not ask if it was an emergency or if she needed the catheter immediately. The Medical Record/ Central Supply Manager did not respond to any further questions.Interview on 04/09/2026 at 9:45 am Resident #16 stated he was not in pain and stated the catheter was perfect. He stated he should have reported him being in pain sooner, but he thought the pain would get better.Interview on 04/10/2026 at 8:05 am the Administrator stated her expectations were all supplies in the facility to be documented on a form and for the Central Supply Manager to make rounds every day to ensure there was adequate supplies in the facility. She stated the Central Supply Manager needed to locate the catheter immediately when the nurse reported to her about needing the catheter. She stated if the nurses had known it was the wrong catheter size the nurse was expected to contact the physician to determine if a different size catheter could be used and if not, then someone would have purchased the correct catheter at a medical supply store or go to a sister facility in town and obtained the correct size catheter. She stated she had placed Central Supply Manager on a plan and would be monitoring the supplies. The Administrator stated she expected the Central Supply Manager to keep a written copy of supplies and not use her personal phone to take pictures of the supplies. The Administrator stated it was approximately 4:00 pm when the nurse received the catheter from the supply truck and realized at that time it was the wrong size for Resident #16. She stated all staff were being in serviced on how to communicate ensuring there was an adequate amount of supplies in the facility and not to order just one catheter to order several of different sizes. Interview on 04/10/2026 at 9:25 am LVN K stated he did go to Medical Record/ Central Supply Manager and wrote on the board to order a catheter 22 F 10 ml foley catheter for another resident. He showed the physician order for the other resident, and it was the same size catheter he stated he requested. LVN K stated when he found out on Thursday the catheter was not in the facility for the other resident he called the Physician and ordered a different size catheter than the facility had in the central supply room. He stated sometimes there was not very good communication in place to communicate with the Medical Record/ Central Supply Manager. LVN K stated writing on the board helps most of the time. Interview on 04/10/2026 at 9:52 am The Director of Nurses stated if a nurse is needing a specific size catheter and there is not one in the facility the nurse was expected to call the physician and discuss the issue with the physician to determine if another size catheter could be ordered. She stated the staff can always go to a sister facility in town and if they have the supplies needed a catheter can be obtained from a sister facility. The Director of Nurses stated if it was an emergency they would call 911 and have the resident transported to the ER. She stated her expectations were to have supplies in the facility at all times. She stated instead of ordering one catheter size to order several catheters in the same size. The Director of Nurses stated she expected the Medical Records/ Central Supply Manager to check the supplies every day and if there is not a certain medical supply she can always go to the supply store in town or a sister facility to ensure the nursing staff has all the supplies they need to care for the residents. She stated there has been a plan developed to ensure the Medical Record/ Central Supply Staff has a better system to ensure there are medical supplies in the facility at all times. She stated there needed to be a better system to ensure the nursing staff had all the supplies they needed. The Director of Nurses stated if a nurse informed the Medical Records/ Central Supply Manager she needed a catheter for a resident she expected the Medical Records/ Central Supply Manager to locate the catheter immediately on the supply truck. She stated obtaining the catheter was top priority. The Director of Nurses stated she was not aware of the situation until later in the afternoon. She stated if she had been informed of the situation, she would have instructed the nurse to call the physician to order a different size catheter, or the staff would have gone to the sister facility sooner and obtained the correct catheter size.Interview on 04/10/2026 at 10:30 am RN C stated when the nursing department needs supplies and they are not available the nursing staff was expected to write it on a board located in Central Supply Room. She stated there are times when someone is required to go to a sister facility or to a medical supply store and obtain the supplies if the facility does not have them in the building. She stated sometimes it is difficult to locate supplies in the central supply room when the Medical Record / Central Supply Manager was not in the facility. She stated, I am unsure how the Medical Record/ Central Supply Manager system of knowing what needed to be ordered and what supplies were in the facility. In an interview on 4/10/2026 at 10: 45 am CNA M stated there were times the facility did not have the supplies needed to care for the residents such as catheters and wipes. She stated she would inform the nurse of the supplies needed to care for the residents and the nurse would report it to the person in charge of ordering supplies. CNA M stated she forgot the title of the person who places orders for supplies, but she knew where her office was located.In an interview on 04/10/2026 at 11:20 am Medical Record/ Central Supply Manager stated LVN K came into her office and requested a 22 F 10 ml catheter on Thursday 04/02/2026. She stated he did write it on the board and did not have a name of the resident needing the catheter. She stated she assumed it was for Resident #16 due to LVN J was requesting a catheter for him. She stated she told LVN J Resident #16 had a catheter on the truck. She stated she assumed it was Resident #16's catheter but she was not 100 percent certain. She stated she did not ask LVN J what size catheter she was needing for Resident #16. Medical Record/ Central Supply Manager stated she did not look for the catheter until she saw it when unloading the truck. She stated it was around 4:00 PM on 04/08/2026 when she found the catheter and the truck did come to the facility on [DATE] approximately 12:00 pm. She stated she realizes now she needed to have located the catheter immediately. She stated she did not report to LVN J the catheter size she ordered. She stated if she had reported what catheter size was on the truck LVN J would have known immediately it was not for Resident #16. Medical Record/ Central Supply Manager stated LVN K did not report to her who needed the catheter when he requested the order. She stated she did not have an inventory paper record of how she knows what supplies are in the facility. She stated she did not have any form on any computer. She stated she used her personal phone to make pictures of the supplies. The Medical Record/ Central Supply Manager stated she did not ask if this was appropriate to use her personal phone to take pictures of the supplies. She stated it was easier for her. She stated no one in the facility would know anything about the supplies if she was unable to come to work for a long period of time or if she was on vacation and out of town. She stated there was always a possibility it would be difficult to relay the pictures to anyone in the staff from her personal phone if she was on vacation for a week or had to take a leave of absence for several months. She stated she did not ask the nurses if they needed supplies or ask what resident was needing the supplies. She stated she never asked if it was urgent or thought about going to the supply store or a sister facility and getting the supplies the nurses needed until the order arrived at the facility. She stated she needed a better system to communicate with the nurses and a better system of tracking what supplies were in the facility. She stated she had been trained on ordering supplies, but she thought she was doing a good job. The Medical Record/ Central Supply Manager stated trying to find the catheter on 04/08/2026 should have been her top priority and it was urgent for the nurses to have that catheter and when it was given to LVN J she knew immediately it was the wrong size. She stated there had been a few times when she did not order enough supplies but very few times. She stated there was a new plan developed on 04/09/2026 and given to her from the Administrator on ordering and documenting the supplies. Observation on 04/10/2026 at 11:50 am in the central supply closet revealed it was difficult to know where anything was located and if there were extra supplies forthe empty bins in the supply closet. Record review on 04/10/2026 of notebook paper of the inventory of supplies in the facility showed the facility had adequate supplies for the residents. The Medical Record/ Central Supply Manager completed an inventory of supplies in the facility and documented it on notebook paper. Interview on 04/10/2026 at 2:00 pm Medical Record/ Central Supply Manager stated she did not have an inventory form to document the supplies on, and she had to use notebook paper. She stated it would be difficult to keep up with the supplies using notebook paper. She stated she placed an order on Thursdays, and the shipment arrived on Wednesdays. She stated this is what was recorded on the ordering form. Central Supply Manager stated she was expected to order on Thursday for the supplies to arrive on Wednesdays. Record review of the ordering process of supplies, dated 10/23, reflected an order form with the following information on the form:Items on handItems neededIncontinent suppliesBriefsPull ups/ protective underwearMed Pass suppliesGlovesFoley catheter suppliesFoley catheter sizesPersonal care/ Bedside utensilsSterile Water/ Normal SalineBasic Toiletry suppliesGeri SleevesHipsters Ordering process:If your ship date is Monday, order ThursdayIf your ship date is Tuesday, order FridayIf your ship date is Wednesday, order MondayIf your ship date is Thursday, order TuesdayIf your ship date is Friday, order Wednesday

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one (Resident #33) of two residents reviewed for enteral feeding (a tube is inserted directly through the abdomen to the stomach to provide nourishment). The facility failed to ensure RN D attended to a flow error alarm on a feeding pump for 45 minutes for Resident #33 on 04/08/2026. This failure could place residents at risk of malnutrition, pain, and/or significant changes in condition. Findings included: Record review of Resident #33's admission record, dated 04/08/2026, reflected a [AGE] year-old female admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that included dysphagia following cerebral infarction (difficulty swallowing after blood flow to the brain was blocked causing damage to the brain), Gastrostomy status (a tube is inserted directly through the abdomen to the stomach to provide nourishment and medications), unspecified protein-calorie malnutrition (a condition caused by insufficient intake of protein and calories), and aphasia (a language disorder causing difficulty with communication). Record review of Resident #33's order summary, dated 04/08/2026, reflected Enteral Feed Order two times a day Diabetisource AC 65ml/hr continuous. Start water flushes at 25 ml/hr. May hold for ADL's. Record review of Resident #33's discharge MDS, dated [DATE], reflected under Section C - Cognitive Patterns a BIMS was not conducted. Under Staff Assessment for Mental Status, it reflected Resident #33 had a memory problem with short-term memory and was severely impaired for cognitive skills for daily decision making. Section K - Swallowing/Nutritional Status reflected Resident #33 had a feeding tube while a resident. Record review of Resident #33's comprehensive care plan, dated 02/04/2021 and revised last on 11/20/2024 reflected a focus of Potential Risk for Malnutrition with interventions that included Administer enteral feedings as ordered. Record review of Resident #33's comprehensive care plan, dated 02/04/2021 and revised last on 04/07/2026 reflected a focus of The resident requires tube feeding r/t dysphagia (difficulty swallowing) with interventions that included Feedings as ordered. During an observation on 04/08/2026 at 01:34 PM, Resident #33 was laying in bed with a family at bedside, the feeding machine was alarming with error, Flow error clog in line downstream of pump. During an observation on 04/08/2026 at 01:48 PM, Resident #33 remained laying in bed, the family member had left. The feeding pump continued alarming with error, Flow error clog inline downstream of pump. During an observation on 04/08/2026 at 02:03 PM, Resident #33 remained lying in bed with the feeding pump audibly alarming. RN D was observed standing in a doorway in front of her cart, 3 rooms down from Resident #33's room. During an observation on 04/08/2026 at 02:15 PM, Resident #33's feeding pump remained audibly alarming, and RN D remained standing in front of her medication cart, 3 doors down from Resident #33's room. During an interview on 04/08/2026 at 02:16 PM, RN D stated I'm just filling in today, I don't know if you know that when asked how long a feeding pump was supposed to alarm prior to attending to it. RN D was informed that the feeding pump for Resident #33 had been alarming for about 45 minutes and asked if RN D was responsible for the residents. RN D stated, let me go check on that and stopped the interview and walked off to Resident #33's room. During an interview on 04/10/2026 at 12:03 PM, the ADON LVN IPCP E stated she expected staff to respond to feeding pumps that are audibly alarming immediately. She stated there was no reason for a feeding pump to be audibly alarming for 45 minutes. ADON LVN IPCP E stated a feeding pump should not alarm for extended periods of time because it affects the residents' number of calories received per day, so it affects their nutrition. During an interview on 04/10/2026 at 04:22 PM, the Dietician Consultant stated she was familiar with Resident #33. She stated she would expect anyone who heard the feeding pump alarm to notify the charge nurse and the charge nurse to assess the alarm and re-start the feeding pump if needed. She stated if a feeding pump was alarming for 45 minutes, it wouldn't be a really big deal because she is on a slow rate so there was not a significant loss due to the pump alarming. 45 minutes is not that long. She further stated she calculated for the feeding to be less than 24 hours due to the feeding pump being turned off for ADLs. During an interview on 04/10/2026 at 04:42 PM, the Director of Nurses stated she had worked at the facility for about 5 years. She stated she would expect any staff member to attend to a feeding pump that was alarming. She stated if a feeding pump were alarming for 45 minutes, then the resident would not get their full dose feeding and calories as prescribed by the provider. During an interview on 04/10/2026 at 04:50 PM, the Administrator stated she expected staff to respond to feeding pumps immediately if it is alarming. She stated if a feeding pump was alarming for 45 minutes, then it could impact how the resident receives formula or how much they receive. Record review of undated facility policy titled Enteral Nutrition reflected We will provide nutritionally complete enteral or parenteral feedings as ordered by the physician for the nourishment of residents who are unable to eat by mouth.Procedure:.5. Problems with the administration of the tub feeding are monitored and corrected by nursing. The dietitian is responsible for evaluating nutritional adequacy and fluid requirements.

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 4 medication carts ( Medication Cart #1) reviewed for medication storage. The facility failed to ensure Medication Cart #1 was locked and medications were secure and not accessible to other staff, residents or visitors.This failure could place residents at risk of having unauthorized access to prescriptions, biologicals, and over-the-counter medications.Findings include:Observation on 04/09/2026 at 1:03 pm revealed medication cart #1 was unlocked against the wall by the common tv area. The back of the cart was against a half wall with the top open to the tv common area. The drawers of the medication cart were facing the area near the nurse's desk. The locking mechanism was protruding outward on the medication cart. The State Surveyor opened the drawers and captured photos. The med aide responsible (Med Aide O) for the medication cart was in a resident's room on 100 hall. There was not any nursing staff in the area of the unlocked medication cart.Observation on 04/09/2026 at 1:15 pm revealed Med Aide O walked from the 100 hall toward the unlocked medication cart #1.Interview on 04/09/2026 at 1:18 pm, Med Aide O stated she thought she had locked the medication cart before she entered the 100 hall. She stated she could not believe the cart was unlocked. Med Aide O stated she had the only set of keys for that cart. She stated residents and visitors had access to the medications in the medication cart. Med Aide O stated if a resident had ingested another residents' medications there was a possibility the resident may overdose, have an allergic reaction, and may require further care at the hospital. She stated there was a possibility a resident may die from ingesting another residents' medication. She stated she was in-serviced on locking medication carts when she was not obtaining medications from the cart. Med Aide O stated she did not recall the date of the in-service of locking medication carts.Interview on 04/10/2026 at 9:52 am, the Director of Nurses stated the medication carts were expected to be locked unless the nurse was standing at the cart administering medications. She stated if the medication carts were in the hallway and the nurse was not standing at the medication cart it was expected to be locked, no exceptions. She stated a resident had the opportunity to take medications out of the medication cart and if the resident ingested the medications there was a potential a resident may be allergic or overdose on another resident's medications. The Director of Nurses stated there was a possibility the medication could have an interaction with the current medication the resident had been prescribed and may cause a resident to need hospitalization for further assessment and treatment. She stated it was a possibility a resident may die if they were severely allergic to the medication. She stated the staff were in-serviced on locking medication carts. She did not recall the date of the in-service.Record review of the facility's policy on Medication Storage in the Facility, dated 2025, reflected Medications and biologicals are stored safely, securely, and properly. The medication supply is accessible only to license personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, 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 for 1 of 4 (Resident #1) residents reviewed for measurable objectives and timeframes. The facility failed to enter dates into the Care Plan when Resident #1 sustained bruises, and no goal or interventions for the resident's diagnosis of schizophrenia (a mental health disorder). This failure could result in inadequate care due to incomplete and inaccurate care plans. The findings include: Record review of Resident #1's face sheet, dated 12/15/25, reflected a -[AGE] year-old male who was admitted to the facility on [DATE] and re-readmitted [DATE]. Resident #1 had diagnoses which included: TBI (traumatic brain injury), ID (intellectual disability, Schizophrenia (a mental health brain disorder), and seizures. The RP was listed as: a family member. Record review of Resident #1's former quarterly MDS, dated [DATE], reflected a BIMS score of Zero, indicative of severe impairment in cognition. The ADLs for: B/B were listed as incontinent of both bowel and bladder. Transfer and Mobility were listed as total dependence. ROM was listed as: impairment lower. The assistive device was a Geri-chair. Mental Illness diagnosis included: schizophrenia and Major Depression.Record review of Resident #1's CP, undated. revealed the resident Resident #1 had a bruise to right lower leg from swinging his leg over the side of a chair; and abdomen bruising due to Lovenox (blood thinner) injection. [The CP did not document when the bruises occurred.] Further record review of Resident #1's CP did not capture any goal or interventions regarding the resident's' diagnosis of schizophrenia. [The CP documented the end date for the blood thinner was 10/19/25.] Record review of Resident #1's Skin Assessments revealed:12/15/25 [date of surveyor 'entrance] reflected: old brown discoloration to RLE (right lower extremity) above outer ankle. 1.0cm x 0.3cm top of right hand due to recent blood drawing. Record review of Resident #1's physician's orders, dated December 2025, reflected the blood thinner, Lovenox, had an end date of 10/19/25. Further review of the physician's orders reflected the resident was given the medication Benztropine. 1 tablet, 1 MG daily for schizophrenia. Record review of Resident#1's MAR, dated December 2025 reflected no refusals of the Benztropine medication. During an Oobservation and interview on 12/15/25 at 4:53 PM Resident #1 was in bed, not alert and not oriented. Resident was cleaned and groomed. Resident struggled to move his body and respond to the surveyor's presence. The resident's disposition was one of involuntary movements. The call light was in reach; the room was cleaned; there were no fall hazards; and the room was homelike. Floor mat and Geri-chair were present, and a camera was present. The bed was at an angle. The Resident could not answer any direct questions due to his cognition. During an interview on 12/15/25 at 4:00 p.m.PM, the Regional RN stated the bruise to Resident #1's right lower leg occurred on 10/03/25 and confirmed the date of the bruise was not listed in the CP. The Regional RN confirmed the CP did not have a specific goal and interventions for the resident's diagnosis of schizophrenia. The Regional RN stated the CP had to be accurate to avoid confusion as to when the resident acquired the bruise and whether interventions were effective. The Regional RN stated the DON [facility had no DON, and the Regional Nurse had assumed the role] or the charge nurse were responsible for the accuracy of the medical record. During an interview on 12/15/25 at 5:10 PM, the ADO stated that clinical records had to be accurate to provide communication for continuity of care. The ADO added that the CP needed to be accurate because it captured the goals and interventions for Resident #1. The ADO stated the interdisciplinary team developed the CP and the DON was responsible for the accuracy of the clinical record and the CP. During an interview on 12/15/25 at 5:26 PM, the Administrator stated the clinical record, and CP had to be accurate to provide continuity of care. The Administrator had no explanation why the CP for Resident #1 did not reflect a goal or interventions for the diagnosis of schizophrenia. Also, the Administrator stated she could not explain why the bruise that occurred in October 2025 was not captured in the CP. The Administrator stated the DON was responsible for the accuracy of the CP and the clinical record. Record review of the facility's Documentation policy undated, read: .The facility will maintain complete and accurate documentation for each resident on all appropriated clinical records sheets.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 5 residents observed for pharmacy services.The facility failed to assure Resident #1 was aware of the medications that he was administering.This failure could affect residents receiving medications by placing them at risk for medication errors. Findings included:Review of Resident #1's MDS assessment, dated 12/4/2025, reflected he was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses that included unspecified convulsions (A seizure occurs due to an electrical disturbance in the brain, while a convulsion describes the involuntary action of jerking and contraction), schizophrenia, unspecified (a serious mental health condition that affects how people think, feel and behave), weakness (the state or condition of lacking strength), personal history of traumatic brain injury (an injury to the head that affects the way the brain works). Resident #1 BIMS score is 00 which is sever impairment. Review of Resident#1 Care Plan reflected the resident has impaired cognitive function/dementia or impaired thought process, a communication process (mostly non-verbal), he has as ADL Self Care performance deficit. The goal is for the residents to maintain current level of cognitive function through the review date. He will make basic needs known by (gestures, sounds, staff anticipating needs) daily through the review date. Interventions are for staff to monitor, document and report any changes. Review of Resident #1's Physician order, signed and dated by the physician on 9/12/2025, reflected Keppra Oral Solution 100 MG/ML (Levetiracetam) was ordered to be given twice a day for convulsions. This medication is what Resident #1 was provided when the Med Aide did not advise him what she was administering.Observation of video footage of Resident #1 on 11/26/25 at 7:15 PM revealed he was lying in bed with his hands behind his head and the bed was elevated. He was awake and alert. Med Aide knocked on the door and entered the room saying hello twice and advised the resident she had medication for him. She bent over to give the medication to Resident #1 and made sure he swallowed the medication. She asked Resident #1 are you okay? Resident #1 was non-verbal, so no response was heard. Per the Care Plan, the BIMS score and an attempt for an interview with the resident determined Resident #1 was non-verbal. Observation on 12/3/25 at 2:30 PM reflected Resident #1 sitting in his chair in the common area. He appeared to be clean and had no odor when passed by him. He was observed alert and moving around a little bit in the chair watching television. Surveyor attempted to speak with him but due to Resident #1 being non-verbal, there was no response. Interview with NP on 12/4/25 at 10:15 AM revealed there would be no adverse reaction if the staff did or did not mention the name of the medication due to Resident #1's cognitive ability. Interview with Medication Aide on 12/4/25 at 01:08 PM revealed she was reeducated on the process of passing medications to residents. She stated she advises residents of their medications when she passes them to the residents. Medication Aide stated if Resident #1 was not advised of the medication he is given nothing can happen. She stated that it is not appropriate not to advise them but some of the residents know their medications they are given. Interview with DON on 12/4/25 at 02:28 PM revealed there would not be any adverse reaction that could have happened if he was not advised of the medication he takes. She stated Resident #1 is mentally incapable of making judgements and his medications are reviewed monthly by the pharmacist. DON stated they have done in-services and watched medication passes as additional education to ensure staff are advising residents of the medications they are being given. Interview with ADM on 12/4/25 at 03:15 PM revealed Resident #1's medication was properly administered by the Medication Aide in the video footage. She stated he is not cognitively capable of understanding whether he was advised the name of the medication or not, but she did advise him she had medication to give to him. ADM stated she doesn't feel it would have changed the effect of anything because he still received his medication and on time. ADM stated measures they have put into place are reeducating the staff, and they are doing checkoffs to advise staff of the proper procedures related to advising the residents what they are doing and what it is for. Review of a facility policy titled Medication Administration and General Guidelines, undated, reflected the following: Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by legally authorized people to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication, monograph of all medications is available in LinkRx otherwise, authorized personnel should refer to Drug Reference material provided by facility.Checklist for completing proper steps in the administration of medications Washes hands using proper technique Does not handle pills with bare hands Ensures identity of the right resident Explains the administration procedure to the resident Adheres to the 6 Rights of Medication Administration:1) Right Dose2) Right Route3) Right Resident4) Right Medication5) Right Time6) Right Documentation Observes the resident take the medication Documents the administration of each medication on the MAR & Controlled Medications on the Control Sheet Documents the administration of PRN Medications including:a) time givenb) reason it was given (symptoms)c) number of tabletsd) effectiveness Returns the medication to locked storage area

Based on observation, interviews, and record reviews the facility failed to ensure residents were free from significant medication errors for 1 of 7 (Resident #1) residents reviewed for pharmacy services. The facility failed to ensure that Resident #1 was provided pharmacy services to ensure that he did not have a preventable seizure on 9/14/2025 at 8:10AM. The noncompliance was identified as Past Noncompliance (PNC). The IJ template was provided to the facility on [DATE] at 1:25PM. The IJ began on 9/12/2025 at 11:22PM and ended 9/15/2025. The facility corrected the noncompliance before the survey began on 10/08/2025. This failure placed residents at risk for seizures, hospitalization and death.Findings Include: Record Review of Resident #1's Facesheet dated 10/08/2025 revealed a 37 y/o male, admitted to the facility on [DATE]. Diagnoses included unspecified convulsions and personal history of traumatic brain injury (TBI). Review of Resident #1's admission MDS, dated [DATE], reflected no BIMS score, indicating the resident was unable to complete the assessment. Resident #1was categorized as severely impaired regarding his cognitive skills for daily decision making and reflected that he was rarely or never understood. Review of Resident #1's Care plan, dated 10/08/25, reflected a Focus area stating, The resident has a seizure disorder Date Initiated: 09/12/25 and Interventions/Tasks that reflected, Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness of medications. Date Initiated: 09/12/25. Record review of Resident #1's Internal Medicine Discharge summary dated [DATE] and signed by MD C reflected Resident #1 had a seizure at the facility he was at prior to admission. It reflected he was started on Keppra and no further seizure activity was noted after that time.Record review of Resident #1's Medication Administration Record (MAR) printed on 10/08/2025 revealed, and order for Keppra Oral Tablet 500 mg (Levetiracetam) Give 1 tablet by mouth two times a day related to UNSPECIFIED CONVULSIONS. Two of three opportunities to administer Keppra were not administered during the time period starting from the PM dose on 9/12/25 and ending before the AM dose on 9/14/2025 as follows: . *The PM dose on 09/12/2025 is recorded as a 9 by RN A. *The PM dose on 09/13/2025 is recorded as 2 by CMA D. * The order was discontinued on 09/14/2025 at 4:45PM. Further review revealed the legend indicated, 9=Other / See Nurse Notes and 2=Drug Refused. Record review of Resident #1's Progress note dated 09/12/2025 at 11:22PM and signed by RN A reflected the Note Text for the Keppra Oral Tablet 500 mg medication administration stated, unable to arouse resident with verbal and tactile stimuli enough to safely swallow. Record review of Resident #1's Progress note dated 9/13/2025 at 6:16PM signed by CMA D reflected the Note Text for the Keppra Oral Tablet 500 mg medication administration stated, Resident would not open his mouth and kept pressing his lips tightly. Record review of Resident #1's Progress note dated 09/14/2025 at 08:10AM and signed by Weekend Supervisor, reflected, Nsg (nursing) notified by assigned CNA that she had changed the resident's brief; repositioned him. CNA then noted the patient to turn red in the face; mucous appearing drool from the left side of his mouth; BUE extended and stiff; eyes closed; pt (patient) not responsive to verbal or painful stimulation at that time. VS (vital signs) noted to be 116/72 pulse 89 and respirations 27; pulse oximetry on room air was 99%. Pt (patient) noted to have history of Seizure Disorder. Pt (patient) safety maintained at all times. Noted length of active seizure activity was apprx (approximately) 2-2.5 minutes. Pt (patient) then noted to be postictal (the recovery phase after a seizure); eyes remained closed; BUE (bilateral upper extremities) noted to be relaxed; skin color WNL and patient appears relaxed. Staff remained at bedside0819 hrs - Weekend RN notified the DON of event0829 hrs - Weekend RN contacted the [RP] and she requested he be sent to the ED for further evaluation. [RP] stated that she was aware of his last Seizure being on 6/26/2025. 911 was contacted; pt being sent to [ED]. Record review of Resident #1's a Late Entry Event note dated 09/14/2025 at 12:00PM signed by DON, reflected [RP] upset because resident did not get 2 doses of his medication and she was not informed Initial Treatment/New Orders: Keppra Level q (every) 3 months. Resident Statement: NAName of MD/NP notified: [NP] Date/time of notification: 09/14/2025 12:00 PM.Name of RP notified: [RP] Date/time of notification: 09/14/2025 2:00 PM.Interventions: NA Record review of Resident #1's Hospital records dated, 09/14/2025, revealed -LAB RESULTS on 09/14/2025 at 09:22AM reflected a Levetiracetam level of (B) indicating a level of less than 0.2 ug/mL (micrograms per milliliter). Record review of Resident #1's Discharge Instructions from hospital dated 09/14/2025 at 10:48AM reflected Special Instructions stating, The patient's blood work showed an undetectable Keppra level which would imply that he is either not receiving it or no longer is been prescribed it. If the patient has a prescription or orders for Keppra, please ensure that he is being given it this will prevent seizure-like activity. Record review of Resident #1's orders dated 10/8/2025 reflected an active order with a start date of 09/14/2025 at 18:30 for Keppra Oral Solution 100 mg/ml. Give 5 ml by mouth two times a day. Record review of MD assessment of Resident #1 on 9/18/2025 at 11:19AM reflected a note stating, recently had seizure due to low Keppra level.Observation of Resident #1 on 10/08/2025 at 10:00AM revealed he was sitting in the lobby area, watching television with several other residents. He was well groomed. He wore non-skid socks, pants, and a shirt. He was lying, with the head of the chair partially raised, in a geri-chair. He had a fleece blanket over his body. He smiled when spoken to but did not respond. In an interview with MD on 10/08/2025 at 1:55PM he stated he believed Resident #1 was sent out for a seizure with a low Keppra level. He stated he might have missed a dose of the Keppra. He stated he had no other seizures since that day. He stated he thought he may have refused the medication. He stated Resident #1 was nonverbal so he would expect him to use non-verbal movements to indicate a refusal. He stated his expectation was that staff should make multiple attempts with refusals of medication. He stated staff should come back in an hour or two to attempt again. He stated forcing a medication could injure him. He stated that he knew there were time constraints with nursing, but it was well known that their mood could change making them more agreeable to take the medication at a later time. In a phone interview with MD on 10/08/2025 at 3:18PM, he stated that he was not sure of the half life of the medication. He stated that he knew that it did not need a loading dose (large first dose of a medication to achieve the desired drug levels). A phone interview was attempted with CMA D on 10/09/2025 at 8:23AM. Surveyor left a message requesting a call back at that time. In an interview on 10/09/2025 PHARM stated that she would not expect an accumulation of prior doses of medication in his system, even if it was not his first dose of medication. She stated that based on half-life of the drug alone, that she would expect undetectable levels if Resident #1 missed the 2/3 opportunities to receive a dose of Keppra on 09/12/2025 and 09/13/2025, when he the Levetiracetam drug levels were drawn on 9/14/2025 at 9:22AM. She stated that there is a correlation between low or undetectable levels of Keppra and seizures. In an email to ADMIN on 10/09/2025 at 9:08AM, surveyor requested a version of the medication administration record for Resident #1 with the times of administration visible. In an interview on 10/09/2025 with NP at 9:10AM, she stated that she was not on call for the weekend of 9/12/2025 through 9/15/2025. She stated that she could see that there was a call from the facility on 9/12/2025 between the hours of 6:00PM to 6:00AM, but stated that she could not read the notes from that call. She stated that she did not see a notification for the on-call provider on 9/13/2025 between 6:00PM to 6:00AM. She stated that she could not recall who told her, but that someone from the facility had told her about the medication refusal for Resident #1 on 9/13/2025 at 12:30PM, and in the afternoon on 9/14/2025 after the seizure activity. She stated that she expected the nurses to notify the provider or the provider on call with medication refusals. She stated that if a resident will not open their mouth, there is not much they can do to give the medication. She stated that, If we don't' give the seizure medication, or if he refuses, the most obvious outcome is that he could have a seizure. She stated that undetectable levels of the medication could cause a seizure. In an interview with DON on 10/09/2025 at 9:56AM, she stated that she was unable to reach CMA D by phone. She stated that she left a message. She stated that she was part of the investigation after Resident #1's seizure. She stated that it made sense that he would have a seizure without any of his seizure medication in his system. She stated that the facility did self-report the incident. She stated that we cannot force a resident to take a medication. She stated, I would expect them to try more than once when residents refuse or when trying to administer a seizure medication. She stated that for the first missed administration on 9/12/2025 the resident was lethargic and the nurse felt it was unsafe to administer the medication. She stated that she knew he refused another dose where he clenched his mouth shut. Surveyor requested the log for the ekit (locked medication dispensing cabinet with emergency medication supply) for the days of the missed doses. In an interview with RN A on 10/09/2025 at 10:28AM, she stated that she worked with Resident #1 on the night of 09/12/2025. She stated that she noticed that the CMA did not give the medication, so she went to the ekit (locked medication dispensing cabinet with emergency medication supply) to remove it and give it to him. She stated that the ekit required an RN to remove the medications and could not be accessed by a CMA. She stated that she could not recall what time it was when she attempted to administer Resident #1's Keppra dose. She stated that she did not attempt to give him the medication later after he was lethargic on the first attempt. She stated that she did not feel safe regarding his ability to swallow the medication. She stated that she should have tried again and that sometimes additional attempts can make a difference for residents' compliance with care and medications. She stated that he could have a seizure if he does not receive his seizure medication. She stated that she did not notify the provider, provider on call, or the RP. She stated that not notifying the physician with seizure medication refusals or missed opportunities to give the medication could result in a seizure for the resident. She stated that not notifying family would result in the family or responsible party not being informed of their loved ones care. She stated that not informing the family or RP may result in a lack of trust in the facility. She stated that not informing the RP of missed medications or refusals could affect the quality of a resident's care. She stated that he had a seizure a few days later. She stated that she was no longer allowed to care for Resident #1 per his RP. In an interview with RNC and Admin on 10/09/2025 at 11:24AM, RNC stated that she expected nurses to notify the RP and the physician with refusals. She stated that the physician should be notified right away with any medication refusals. She stated that the physician and the RP should be notified of a seizure medication refusal at the time of the refusal, regardless of the hour. She stated that the resident could have an adverse reaction if we are not notifying the physician and the RP at the time the medication is missed. In an interview with the DON on 10/09/2025 at 4:35PM, she stated that as part of the investigation and follow up regarding the seizure for Resident #1, the facility did an audit on all residents with seizure medications and found that all other residents were given their medication appropriately. She stated that she in-service the staff about reporting missed medications to the MD or NP immediately. She stated that RNC was working to provide the ekit log. She stated that it was her responsibility to check a report that will analyze the medication administration records to review the documentation for medication refusals and occurrences where a nurse references a nurses note with their administration. She stated that she checks to see the reason for refusal and review the documentation surrounding the occurrence for anything concerning. She stated that she monitors the report on weekdays. She stated that she tries to investigate and address the root cause of repeated refusals or do some lab work if it is a new behavior for the resident. She stated that they also worked with the NP to do a random drug level lab screening for the residents with seizure medications that were appropriate for testing. She stated that she reviewed all the residents in the facility that were on seizure medications, to ensure they had regular lab monitoring orders as appropriate for their seizure medications. In an interview with ADON on 10/10/2025 at 3:57PM, she stated that nurses should attempt to administer a seizure medication more than once before documenting a refusal or missed dose. She stated that they should also find out why the resident refused the medication. She stated it was the nurses responsibility to then let the family and the physician know that the resident did not take their medication. She stated the Care plan should be updated after the refusal. She stated that nurses should notify the MD or NP on call if refusals are taken overnight or on off hours. She stated that if residents do not receive their seizure medication they can have seizures or seizure like activity. She stated that the facility had liberalized medication times and the evening dose could be administered between 5:00PM-10:00PM unless specified in the order. She stated that staff have until 11:00PM to give the medication. Observation and review of medication administration on 10/08/2025 at 10:06AM with CMA E revealed no medication errors. Observation and review of Medication Storage room for the facility on 10/08/2025 at 11:06AM with LVN F revealed no concerns for noncompliance related to medication storage. Observation of Resident #1 on 10/08/2025, 10/09/2025, and 10/10/2025 revealed no significant findings. No signs of distress or change in mood or abilities from his documented baseline care plan function. Record review of Resident #1's MAR on 10/08/2025 and10/09/2025 revealed that he received all subsequent doses of Keppra after 09/14/2025. The administrator was notified of the PNC IJ on 10/10/25 at 1:25 PM. The IJ began on 09/15/2025 and ended on 09/15/2025.The following actions were taken by the facility prior to surveyor entering on 10/08/2025 to abate the IJ: In an interview with RNC on 10/09/2025 at 5:13PM, she stated that there was no documentation submitted with Champion Rounds that are completed by administrative staff. She stated that the staff are instructed to review areas related to quality of care. She stated that any findings are brought up in the morning meeting and discussed daily during the weekdays. She stated that the administrative teams discussed any issues potentially reportable to the state, any concerns with morning rounds including behaviors, grievances, falls, skin issues, self-reported investigations, injuries of unknown origin, dietary concerns, activity concerns, transportation related concerns or plans, and/or social services concerns. She stated that the facility also generates and analyzes a real time report that examines some several thousand key words to do an overview of potential occurrences that would need to be addressed. Record review of Employee Disciplinary report with a dated of infraction listed as 9/13/2025 reflected RN A was put on investigatory suspension. The form is signed by RN A and DON with a date listed as 9/17/2025. Interviews with 3 LVNs, 1 RN, 1 CNA, and 2 CMAs from 10/08/2025 to 10/10/2025 revealed all were knowledgeable of responsibilities related to facility policy for abuse, neglect, and exploitation, including when and who to report to if any are observed. Interviews with 3 LVNs, 1 RN, and 2 CMAs from 10/08/2025 to 10/10/2025 revealed all were knowledgeable of responsibilities related to refusals of medications, including notifications to provider and RP, responsibility to educate the resident or representative regarding the consequences of missed doses of medications, and making more than one attempt to administer a seizure medication. All were knowledgeable of Resident #1's care and precautions. Record review of facility self-reported intake was submitted to the State of Texas Complaint and Incident Intake via email on 9/14/2025 at 2:30PM. Record review of In-services dated 9/14/2025, reflected: *Customer Service, Abuse and Neglect Reporting reflected 23 signatures across all departments from a roster of 53 staff, *Reporting Medication Refusals and Missed Medications, Do Not Crush Medication Notice in-service instructed by DON reflected 13 signatures of a roster of 13 medication aides and nurses, *Reporting Missed Medications in-service instructed by DON reflected 9 signatures of a roster of 13 medication aides and nurses, *Reconciling medications upon admissions/Readmissions, and Change in Condition Notification in-service instructed by DON reflected 12 signatures of a roster of 13 medication aides and nurses, and*Properly reconciling medication administration in-service instructed by DON reflected 12 signatures of a roster of 13 medication aides and nurses. Record review of Care plan update dated 9/14/2025 reflected a Focus area stating, The Resident is non-compliant with medication administration will clamp mouth shut tight Date Initiated: 09/14/2025. Record review of NP assessment of Resident #1 was documented with a dated of service listed as 9/15/2025 at 00:00PM. Record review of Trauma Informed PRN assessment dated [DATE] at 5:15PM and signed by SW, reflected a trauma assessment was completed with Resident #1's RP. Record review of Abuse and Neglect related surveys for Residents dated 09/15/2025 and signed by SW reflected 45 resident interviews. All interviews with residents reflected all residents interviewed felt safe, were content at the facility, knew how to report abuse or neglect and denied any uncomfortable encounters with staff or other residents. Record review of SW notes on 9/16/2025 at 5:58PM reflected Resident #1 was assessed and showed no signs of distress. Record review of In-service signed by DON and dated 09/17/2025 reflected Resident #1 will be increased to hourly rounding with the following checked as part of the rounds: Call light and personal items (e.g. remote, water) within easy reach, bed in low position with fall mat, positioned with pillows, resident comfortable and repositioned every 2 hours, check for incontinence and assist with cleanup if needed, check if the resident is noted to be in any distress, ensure bed linens are clean, and ensure the room is clean. There are 54 staff signatures listed from all departments, no roster was attached with the in-service. Record review of Resident #1's Hourly Rounding form dated 9/17/2025-10/07/2025 reflected initials from staff members on hourly intervals with notes about the position and activity of the resident and some care performed with the round. Record review of blank Champion Rounds checklist reflected columns for all weekdays with areas for observations related to areas related to Resident Comfort, Resident Equipment, Hazards/Personal Care, and Housekeeping Resident Room. These include categories related to: Call light out of reach, water out of reach, privacy, resident concerns, dirty medical equipment, personal care items at bedside, trash removed, room unkept, etc. Record review of Resident #1's PSYCH NP assessment on 09/19/2025 at 5:32PM reflected, Resident resting on Geri chair at community area appears comfortable with no distress, awake & nonverbal baseline per medical records. Record review of 15 anonymous staff questionnaire's (no date) regarding any knowledge of abuse or neglect, any knowledge of Resident #1's compliance with care and medications, any knowledge of refusals for other residents, and when and whom to report any abuse revealed there were no reports of abuse in the facility, none reported refusals from Resident #1 or other residents, and all were knowledgeable of the Abuse and Neglect Coordinator and to report abuse immediately. 10 of the forms contain handwritten signatures. 3 forms have handwritten dates of 9/15/2025 and 2 forms are dated 9/14/2025. Record review of Seizure Medication Administration Monitoring form signed by DON with review dates of 9/15/25, 9/16/25, 9/17/25, 9/18/25, 9/19/25, 9/20/25, 9/21/25, 9/22/25, 9/23/25, 9/25/25, 9/26/25, 9/27/25, 9/28/25, 9/29/25, 9/30/25, 10/01/25, 10/02/25, 10/03/25, 10/04/25, 10/05/25, 10/06/25, 10/07/25, 10/08/25, 10/09/25, and 10/10/25; stating that all anticonvulsant medications were given with no corrective action required. Record review of Anticonvulsant Audit form signed by DON (no date) reflected 13 residents with anticonvulsant medications were audited. Three missed medication opportunities were noted for other residents in September 2025, all while residents were out of the building. Lab monitoring was also reviewed in this audit. There was no missed medication opportunities noted for August 2025. Review of Competencies for Aides forms reflected 1 CNA was evaluated by ADON in July 2025, 1 CNA was evaluated by ADON in August 2025, 2 CNAs were evaluated by ADON in September 2025. These competencies include observations of incontinent care, transfers of various types including a mechanical lift, ambulation assistance techniques, feeding a resident, repositioning a resident in bed with 1 or 2 assist of staff, urinary catheter care, various forms of toileting assistance, and post mortem care. Facility policy for Medication Administration and General Guidelines (2025) reflected, PolicyMedications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication, monograph of all medications is available in LinkRx otherwise authorized personnel should refer to Drug Reference material provided by facility.1. Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or otherpersonnel authorized by state laws and regulations to administer medications.2. Medications are administered in accordance with written orders of the attending physician. If a dose seemsexcessive considering the resident's age and condition, or a medication order seems to be unrelated to theresident's current diagnosis or condition, the physician is contacted for clarification prior to the administration.of the medication. The interaction with the physician is documented in the nursing notes and elsewhere in themedical record as appropriate.10. Medications are administered within one hour of the scheduled time, unless the physician specifies a specifictime then the med must be given 30 minutes prior to 30 minutes after the specified time (unless facility policydirects otherwise). Before or after meal orders are administered precisely as ordered. Unless otherwisespecified by the physician, routine medications are administered according to the established medicationadministration schedule for the facility.12. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (e.g.resident not in facility at scheduled dose time, initial dose of antibiotic), the space provided on the front of theMAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side ofthe record provided for PRN documentation. The physician must be notified when a dose of medication has notbeen given. If an electronic medical record is being utilized than the caregiver administering the medication willenter the correct documentation that will then be electronically date/time stamped with their initials. Facility policy for Notifying the Physician of Change in Status (no date) reflected: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. 1. The nurse will notify the physician or their delegated nurse practitioner or physician assistant with change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. 2. Before the physician is contacted, the nurse will gather and organize resident information. Applicable information will include current medications, vital signs, signs and symptoms initiating call, current laboratory information, and interventions that have currently been implemented. 3. The nurse may collect several non-emergent items and place one telephone call during the shift in order to avoid multiple calls to a physician with non-emergent questions. The nurse is responsible, however, for responding to a change of condition in a timely and effective manner. The nurse will document the time of the call to the physician in the clinical record. 4. If the physician does not return the call within a reasonable amount of time, the nurse will attempt to contact the physician a second time. If the situation is an emergency, and the physician does not call back within a reasonable amount of time, the nurse will contact the Medical Director or the nearest ambulance service for assistance. The nurse will document all attempts to contact the physician in the resident's clinical record. 5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise. 6. The nurse will monitor and reassess the resident's status and response to interventions. Physicians should develop a working diagnosis and guide nursing staff in what to monitor, and when to notify the physician if the resident's condition does not improve. 7. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's orders and the resident's status and response to interventions.The noncompliance was identified as Past Noncompliance (PNC). The IJ template was provided to the facility on [DATE] at 1:25PM. The IJ began on 9/12/2025 at 11:22PM and ended 9/15/2025. The facility corrected the noncompliance before the survey began on 10/08/2025.

Based on observation, interview, and record review the facility failed to provide the care and supervision to prevent accidents for 1 of 7 (Resident #1) residents reviewed for accidents and hazards. The facility failed to ensure that Resident #1 was repositioned with two-person assist and left in an unsafe position when CNA A walked away from the bedside on 9/15/2025. The noncompliance was identified as Past Noncompliance (PNC). The IJ template was provided to the facility on [DATE] at 1:25PM. The IJ began on 9/12/2025 and ended 9/15/2025. The facility corrected the noncompliance before the survey began on 10/08/2025. This failure placed residents at risk for accidents, falls, fractures, and diminished quality of life.Findings Include: Record Review of Resident #1's Facesheet dated 10/08/2025 revealed a 37 y/o male, admitted to the facility on [DATE]. Diagnoses included unspecified convulsions, schizophrenia, weakness, and personal history of traumatic brain injury (TBI). Record review of Resident #1's admission MDS, dated [DATE], reflected no BIMS score. Section GG -Functional Abilities - admission section reflected Resident #1 was categorized as dependent on staff for all forms of mobility that could be safely assessed at that time. Record review of Resident #1's Care plan, dated 10/08/2025, reflected a Focus area stating, The resident is risk for falls r/t Gait/balance problems, Incontinence, Poor communication/comprehension Date Initiated: 09/12/2025 with Interventions/Tasks stating, Anticipate resident's needs. Date Initiated: 09/12/2025. Additional Focus area stating, The resident has an ADL Self Care Performance Deficit Date Initiated: 09/12/2025, with Interventions/Tasks stating, Bed Mobility: requires staff x2 for assistance Date Initiated: 09/12/2025. Record review of Resident #1's Progress Notes dated 10/08/2025 reflected no falls since his admission on [DATE]. Observation of Resident #1 on 10/08/2025 at 10:00AM revealed he was sitting in the lobby area, watching television with several other residents. He was well groomed. He wore non-skid socks, pants, and a shirt. He was lying, with the head of the chair partially raised, in a geri-chair. He had a fleece blanket over his body. He smiled when spoken to but did not respond. Observation of video on 10/9/25 (no time/date stamp), revealed Resident A lying on the bed wearing only a brief, with only a fitted sheet on the bed and his body fully exposed. There are fall mats on both sides of the bed. The bed was in a raised position. Both of his feet are hanging off the left side of the bed. CNA A was standing on the left side of the bed. She attempted to move his feet into the bed, but they bumped the footboard of the bed and moved back to their position off the bed, due to the rigidity of his muscles. She walked to the right side of the bed at the head of the bed and attempted to use the sheet beneath him to pull him up in the bed. The pulling motion resulted in Resident #1 being in a diagonal position with his head on the top, right edge of the bed and his legs positioned off the bed to the level of his knee on his left leg and his foot on the right leg. She attempted to turn Resident #1 on his left side but the resident became more rigid and resisted the movement toward the right side of the bed. She walked to the left side of the bed and tried to push the residents' legs in the bed, assisting him to bend his knees, and rolled him on his right side, holding his body with one hand, she adjusted his brief with the other hand. She then assisted Resident #1 to lay on his back, and due to his muscle tension, his legs and torso moved to being in a position with both legs off the bed up to his knees on the left side of the bed, and in a diagonal position with his head on the edge of the top, right side of the bed. His brief was unfastened on his right side from the movement. CNA A stated, I can't be doing this all day. CNA A walked away from the bedside toward the door. Observation on 10/10/2025 of Video dated 9/15 at 9:41:15 AM revealed CNA A with Resident #1. Resident #1 is lying in bed on his right side with CNA A on the right side of the bed. The bed was in a raised position with fall mats on both sides of the bed. The resident was wearing a brief with no sheets covering his body. The video fast forwards to Resident #1 laying in a diagonal position across the bed with his legs hanging off the bed up to his knees and his head at the top, left edge of the bed. At the time stamp 9:41:31 AM it continued at normal playing speed, CNA A, still standing on the right side of the bed, walked away from Resident #1's bedside and was heard saying, I can't be doing this all day as she walked to the door. She left the room at 9:41:35 AM. Resident #1's call light was not in reach. The cord can be seen at the top right of the headboard. CNA A returned to the room at 9:42:37 AM with a female staff member. The video cut off momentarily and returned at time label, 9/15 9:42:44 AM. CNA A was standing in front of the cabinet with the camera. The camera view was slightly lower than the previous view. The head of the bed was no longer visible. CNA A and a second staff member (name tag not visible in the video) put on Resident#1's shirt and shorts. CNA A stated, He's a fall risk. Two staff members reposition Resident #1 into the bed with his head at the top of the bed, body midline, and feet above the footboard. The two staff members are still in the room at the close of the video and the bed was raised. Interview with DON on 10/09/2025 at 9:33AM, she stated she had seen and investigated Resident #1's care related to the video from 09/15/2025. She stated she thought the CNA A may have just yelled out the door or came right back with help. She stated she was not sure if she left or for how long. She stated CNA A should not have stepped away from the bedside for any length of time with the bed in the high position and Resident #1's legs hanging off the bed. She stated that he was at high risk of falling from that position. Interview with the Admin, RNC, and Corporate Admin on 10/9/2025 at 3:03PM, the Admin stated she had seen the video of Resident #1 being repositioned by CNA A. She stated the facility had received the video and self-reported the incident. They stated the incident took place on 09/15/2025 and CNA A was immediately suspended and later let go based on customer service concerns. She stated the facility investigation found while the aide was repositioning Resident #1 and the resident tended to push back or become stiff. She stated when CNA A realized she could not reposition him effectively on her own, she went and got help. She stated she did not know how long the resident was alone in the room at the end of the video. She stated CNA A stated she got help right away and was back within minutes at the longest. The RNC and Admin stated that leaving the resident with the bed raised and his legs hanging off the side of the bed was not a safe position to leave him unsupervised for any amount of time. Admin stated that he could slide off the bed. Admin stated that the resident was care planned for assist of 2 with repositioning and transfers. They stated the CNA should not have attempted to reposition him alone. The Admin and Corporate Admin stated that was also part of why they separated ways with that employee. The Admin stated she was concerned with the video's content and which was why she started an investigation of her own. The Admin and Corporate Admin stated they learned from this incident. The Corporate Admin stated staff was in-service on abuse, neglect, and exploitation and resident rights. She stated the CNA involved was interviewed and stated they should have used two people to reposition Resident #1 in bed. Despite the admission from the CNA, the company decided to sever ties with CNA A. She stated that Resident #1 was assessed and found to have no injuries. She stated that safe surveys were completed for all residents who were interviewable, and skin assessments were performed for those that were not able to communicate, with no findings. She stated that staff were also interviewed regarding any other issues, with no new findings. Admin and Corporate Admin stated that the facility is thoroughly investigating all incidents reported to the facility and learning from them to improve all resident care. Interview with DON on 10/09/2025 at 4:35PM, she stated that Resident #1's video of care from 9/15/2025 revealed the resident was not left in a safe position when CNA A walked away from the bedside after attempting to reposition the resident. She stated Resident #1 could fall if left in an unsafe position, especially with the bed raised to the high position. She stated it was not a safe position for a resident to walk away from the bedside or leave the room for any amount of time. She stated Resident #1 should have been transferred with two people. She stated the CNA A should have checked the Kardex (a care synopsis generated from the resident care plans). She stated Resident #1 was a known fall risk and known to require two staff for repositioning and transfers on 9/15/2025. She stated [TT7] residents do not need to have interventions stating a resident should have a lowered bed after care. She stated it was a standard of care to lower the bed when staff leave the room, unless it's the residents preference. She stated the person providing care was the one responsible for ensuring safe positioning of residents after care provided. She stated she was responsible for ensuring residents are following fall precautions. She stated the Charge nurses and ADON are also responsible for ensuring fall precautions are being used consistently. She stated it was part of the champion rounds observations every weekday from all department heads. She stated she was not aware of the situation in the video prior to seeing the video. She stated that as a way to monitor residents for safety and positioning, the administrative staff do Champion rounds to monitor their assigned residents for their body positioning, cleanliness, and staff interactions. She stated that nursing administration regularly watched incontinent care and resident transfers with staff as part of their annual competencies for direct care staff, on hire training, and if there was any concerns. In an interview with RNC on 10/09/2025 at 5:13PM, she stated that there was no documentation submitted with Champion Rounds [TT8] that are completed by administrative staff. She stated that the staff are instructed to review areas related to quality of care. She stated that any findings are brought up in the morning meeting and discussed daily during the weekdays. She stated that the administrative teams discussed any issues potentially reportable to the state, any concerns with morning rounds including behaviors, grievances, falls, skin issues, self-reported investigations, injuries of unknown origin, dietary concerns, activity concerns, transportation related concerns or plans, and/or social services concerns. She stated that the facility also generates and analyzes a real time report that examines some several thousand key words to do an overview of potential occurrences that would need to be addressed. Interview with ADON on 10/10/2025 at 03:57PM, she stated that staff should read the resident Kardex and ask the charge nurse if they are unsure of the level of assistance a resident requires for care. She stated that a resident can be hurt if we do not use the appropriate amount of staff when caring for residents. The PNC IJ was identified on 10/10/2025 at 1:25 PM and the administrator was notified the IJ began on 09/12/25 and ended 09/15/25.The following actions were taken by the facility prior to surveyor entering on 10/08/2025 to abate the IJ: Interview with SW on 10/10/2025 at 4:04PM, she stated that she had assessed Resident #1 after all allegations or complaints regarding his care. She stated that Resident #1 had been his normal self from what the facility has experienced of him. She stated that he smiled occasionally and watched television. She stated that Resident #1 was non-verbal. She stated that she performed a trauma assessment after the incident on 09/15/2025 with Resident #1's RP. She denied any change in demeanor, episodes of tearfulness, or increase in behaviors noted by herself or reported by staff. Observations of residents in the facility on 10/08/2025-10/10/2025 revealed that 3 of 3 had assigned fall interventions in place per their care plan interventions with call light in reach when in their room. Interviews with 3 LVNs, 1 RN, 1 CNA, and 2 CMAs from 10/08/2025 to 10/10/2025 revealed all were knowledgeable of responsibilities related to facility policy for abuse, neglect, and exploitation, including when and who to report to if any are observed. All were knowledgeable of care and precautions related to Resident #1. Record review of Employee Disciplinary Report for CNA A with an infraction date of 09/15/2025 reflected an Investigatory Suspension was initiated on 09/15/2025. Employment Status print out for CNA A on 09/15/2025 reflected she was involuntarily terminated from employment on that day. Record review of related In-services on 09/15/2025 reflected a in-services for Abuse and Neglect signed by nursing, dietary, housekeeping, therapy departments, and administrative personnel with 67 signatures and an in-service for Resident Rights signed by nursing, dietary, housekeeping, and therapy departments with 41 signatures and a roster of 75 staff members attached. Record review of Staff Interview and In-service forms dated 09/15/2025, reflected staff a questionnaire regarding any knowledge of abuse in the facility, who to report allegations of abuse or neglect to, what would staff do if they heard or witnessed abuse, and asked to name examples of abuse and neglect. There are 31 forms filled out by staff. None of the respondents stated they witnessed any abuse in the facility and all were knowledgeable of their reporting responsibilities and able to name a form of abuse or neglect. Record review of In-service signed by DON and dated 09/17/2025 reflected Resident #1 will be increased to hourly rounding with the following checked as part of the rounds: Call light and personal items (e.g. remote, water) within easy reach, bed in low position with fall mat, positioned with pillows, resident comfortable and repositioned every 2 hours, check for incontinence and assist with cleanup if needed, check if the resident is noted to be in any distress, ensure bed linens are clean, and ensure the room is clean. There are 54 staff signatures listed from all departments, no roster was attached with the in-service. Record review of Resident #1's Hourly Rounding form dated 9/17/2025-10/07/2025 reflected initials from staff members on hourly intervals with notes about the position and activity of the resident and some care performed with the round. Record review of blank Champion Rounds checklist reflected columns for all weekdays with areas for observations related to areas related to Resident Comfort, Resident Equipment, Hazards/Personal Care, and Housekeeping Resident Room. These include categories related to: Call light out of reach, water out of reach, privacy, resident concerns, dirty medical equipment, personal care items at bedside, trash removed, room unkept, etc. Record review of Abuse and Neglect related surveys for Residents dated 09/15/2025 and signed by SW reflected 45 resident interviews. All interviews with residents reflected all residents interviewed felt safe, were content at the facility, knew how to report abuse or neglect and denied any uncomfortable encounters with staff or other residents. Record review of Trauma Informed PRN assessment dated [DATE] at 5:15PM and signed by SW, reflected a trauma assessment was completed with Resident #1's RP. Record review of Resident #1's Progress Notes on 9/15/2025 reflected a weekly skin assessment was completed and signed by TN at 5:27PM. There were no abnormal findings in the assessment. Record review of Resident #1's Event Note signed by DON on 9/15/2025 at 6:06PM reflected an allegation that Resident #1's dignity was not maintained during care, skin assessment was performed with no negative findings, and the MD and RP were notified. Record review of Resident #1's note signed by SW on 09/16/2025 at 5:58PM reflected a follow-up assessment stating that the resident appeared calm and comfortable. Record review of Resident #1's PSYCH NP assessment on 09/19/2025 at 5:32PM reflected, Resident resting on Geri chair at community area appears comfortable with no distress, awake & nonverbal baseline per medical records. Her recommendations included: -Safety: At this time patient is not an acute danger to self or others, however this may change based on treatment compliance and psychosocial stressors. Provide resident trauma informed care.-Manage resident's environment with reinforcement of day/night cycle (blinds open during the day; quite at night), frequent reorientation, staff continuity and overall stimulus reduction. Record review of Resident #1's Care plan printed on 10/8/2025 reflected Focus area addressing Resident #1's history of trauma was initiated on 09/16/2025 with related goals and interventions. A Focus area stating, Resident is resistive to care r/t (related to) TBI. Resident legs and arms are very stiff when staff try to turn him he pushes back with his body Date Initiated: 09/15/2025, with related interventions including, If resident resists with ADLs, reassure resident, ensure safety, leave and return 5-10 minutes later and try again. Date Initiated: 09/15/2025 Created by: DON. Record review of Resident #1's MD assessment on 09/19/2025 at 11:26AM, reflected Resident #1's condition was stable. Plan included continuing current medication orders and to continue supportive care. Review of facility policy Fall Policy reflected: Preventing falls requires an interdisciplinary program that focuses on modifying the extrinsic factors, correcting intrinsic factors, and educating the resident and family. A Fall Risk Assessment will be completed on admission and after each fall. The MDS 3.0 will also assist in determining a resident who is a fall risk. Procedure 1. On admission, the nurse will complete a fall risk assessment for each resident. 2. If the resident is unable to assist in completion of the tool, or if medical records are unavailable, the nurse may obtain the assistance of a family member or legal representative that is familiar with the resident's current functional status. 3. Fall Risk Assessment The Fall Risk Assessment Tool will be completed at admission and after each fall occurrence. The assessment should be completed by reviewing the resident's medical history, social history, and current functional status. Information may be obtained by reviewing current medical records, interview with resident/family, or conference with the interdisciplinary team members. The assessment tool should be scored and interventions implemented as indicated. The MDS completed on admission, quarterly and upon significant change will also assess for fall risk 4. Appropriate interventions will be addressed immediately on the interdisciplinary plan of care. Reassessment will occur after each fall. 5. Interventions will be resident centered. See Appendix A for Fall Intervention Methods on the following pages.17. Appropriate education will be provided to all staff members as needed on fall prevention. The noncompliance was identified as Past Noncompliance (PNC). The IJ template was provided to the facility on [DATE] at 1:25PM. The IJ began on 9/12/2025 and ended 9/15/2025. The facility corrected the noncompliance before the survey began on 10/08/2025.

Based on observation, interview, and record review, the facility failed to provide and document an effective discharge planning process that focused on the resident's discharge goals, the preparation of the residents to be active partners and effectively transition them to post discharge care, and the reduction of factors leading to preventable readmissions for 1 of 6 (Resident #1) of residents reviewed for safe discharge. On 4/26/2024 the facility discharged Resident #1 from the facility pending a hearing for an appeal. The facility transported Resident #1 and all of his belongings to RP1's home. There was no one at the home who was able to accept Resident #1, the facility left the resident sitting outside of the home that was located on a busy street. Resident #1 was considered blind, was moderately cognitively impaired, was at risk for elopement with a previous history of elopement. The facility failed to ensure a safe discharge for Resident #1 when the facility dropped Resident #1 off at his RP1's home on the front porch unsupervised. The facility failed to ensure and coordinate the discharge of Resident #1 with RP1. The facility failed to ensure the completion of the discharge appeal process prior to discharging Resident #1 An (IJ) Immediate Jeopardy was identified on 4/27/2024 at 3:40 p.m. The IJ Immediate Jeopardy template was provided to the Admin on 4/27/2024 at 3:40 p.m. While the (IJ) Immediate Jeopardy was removed on 4/30/2024 at 4:05 p.m., the facility remained out of compliance at a scope of isolated and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This failure could place residents at risk of an unsafe discharge from facility leading to hospitalization , injury, elopement, and death. Findings included: Record review of Resident #1's face sheet dated 4/27/2024 reflected, Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Unspecified Dementia (when symptoms and findings of cognitive dysfunction do not meet the criteria for a specific type of dementia), Unspecified Severity, without behavioral disturbance, psychotic disturbance (paranoid or delusional), mood disturbance (depression), and anxiety (worry), and blind. The face sheet listed RP 1 and RP 2 as the RP's for Resident #1. Record review of Resident #1's quarterly MDS dated [DATE] reflected in Section A identification information indicated Resident #1 preferred language was Spanish. Under section C cognitive patterns reflected a BIMS score of 8 indicating moderate impairment for daily decision making. Under section G functional status and ADL's reflected Resident #1 required supervision with transfers, eating, toileting. Record review of Resident #1's care plan dated 4/25/2024 reflected Resident #1 had impaired vision, at risk for falls due to vision, confusion and poor comprehension. The care plan reflected Resident #1 was an elopement risk and a previous elopement from the facility on 10/22/2023. Interventions indicated watch for wandering behaviors, request to leave, attempt to leave facility, home, or hospital. The care reflected an ADL performance deficit and required 1x staff assistance with bathing, mobility, toileting, and dressing. The care plan also reflected that a discharge from the facility is not feasible as evidenced by Resident #1's dementia, inability to care for himself, administer medications, and recognize a change in condition. In an interview via phone on 4/26/2024 at 12:30 p.m. with Resident #1 RP2, she stated the facility dropped Resident #1 off on Resident #1's RP1's front porch. She stated there was no one home and she was leaving as soon as possible to go to the home because Resident #1 was unattended. She stated she could see him on the camera all alone with his belongings. In a follow-up interview she stated she arrived to find Resident #1 confused on the doorstep of RP1's home. She reported it took her about 15 minutes to get to home, so Resident #1 was there for that period of time with no supervision. She stated Resident #1 did not know where he was and thought he was in a different state. She did not understand how the facility could leave him unattended when there is a busy street nearby. She stated he could have fallen or been hit by a car. She stated they did receive a discharge notice from the facility but filed an appeal with the assistance of an ombudsman. She stated she thought the facility could not discharge Resident #1 until the appeal was decided. She stated they cannot care for Resident #1 at home as his medical needs are high and that is why he required nursing facility care. In an interview on 4/27/2024 at 12:45 p.m. the Admin stated on 4/26/2024 she and other staff members dropped Resident # 1 off at RP1's home. The Admin stated on 4/23/2024 the facility issued the family an emergency discharge of Resident #1 due to ongoing behaviors at the facility. The Admin stated the family did file and appeal for this discharge she stated the facility moved forward with the discharge and did not wait on the appeal process because they had already spoken with the family and started the discharge process due to the residents behavior. The Admin stated they provided the family with three choices for Resident #1, she stated they tried to locate another placement for the resident, and none were found. She stated the facility tried to get Resident #1 sent to the behavioral psychiatric hospital, she stated he was not accepted because he was not having current behaviors. The Admin stated the last choice was Resident #1 was going to be discharged to the family. She stated the family was going to have a family meeting on 4/25/2024 and let the facility know what they decided. The Admin stated she never heard back from the family so the facility discharged Resident #1 to RP1's home on 4/26/2024. The Admin stated she was not aware of who the person was who answered the door, but stated it was not either of the RPs for Resident #1. The Admin stated when they dropped Resident #1 off at the home they did not speak with or see either of the RPs for Resident #1 but thought they may have been in the home. The Admin stated she left the aftercare service for Resident #1 on the porch along with his other personal items. In an interview on 4/27/2024 at 1:55 p.m. with Admissions Coordinator revealed she assisted with the discharge of the resident. Stated they wanted to ensure that the family was home. She stated someone did answer the door and stated the Admin. provided whoever answered the door the resident's medications. She stated when they got ready to leave whoever answered the door opened the door and threw the residents medications outside on the bench where the Resident #1 was sitting. She stated the resident tried to get up and walk away and stated their CNA A spoke with the resident in Spanish and advised him to continue to sit on the porch. She stated the Admin. called the police to complete a welfare check and stated she also called APS because someone, whoever was in the house did not allow Resident #1 to come into the home and closed the door. In an interview via phone on 4/27/2024 at 2:10 p.m. with BOM revealed they took the resident to RP1's house and stated they went to the door and a lady answered the door. Stated the Admin. spoke with the person who answered the door that this was the resident's medications, and this was the provider aftercare information. She stated the lady took the medication and closed the door, then she opened the door and started speaking in Spanish and threw the medications out on the bench. She stated before they were leaving the resident started walking down the driveway with his walker and stated they went back and talked with the resident about sitting in the chair and waiting for his daughter to come. She stated the other staff were speaking to him in Spanish because he does not speak English that good. She stated they unloaded his stuff and left it on the porch and stated they were not there that long. She stated she did not think that this person spoke English. Record review of facility discharge policy dated 11/28/2016 that reflected the following: The facility must discharge planning when you anticipate discharging a resident to a private home, another nursing facility or skilled nursing facility or any type, or another type of residential facility. The Admin was notified on 4/27/2024 at 3:40 p.m., An (IJ) Immediate Jeopardy was identified due to the above failures. The Admin was provided with the (IJ) Immediate Jeopardy template on 4/27/2024 at 3:40 p.m., and a Plan of Removal (POR) was requested. The POR was accepted on 4/30/2024 at 3:32 p.m. The POR included the following: Problem: F660 Discharge Planning On 04/27/2024 an abbreviated survey was initiated at facility. On 4/27/24 the surveyor provided an Immediate Jeopardy (IJ)Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate Jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: 660: The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable Readmissions. The facility failed to ensure a safe discharge for Resident #1 when the facility dropped Resident #1 off at his RP1's home on the front porch unsupervised. The facility failed to ensure and coordinate the discharge of Resident #1 to RP1. The facility failed to ensure the completion of the discharge appeal process prior to discharging Resident #1 Interventions: 1. Resident #1 currently does not reside in the facility as of 4/27/24. Facility contacted family on 04/30/2024 and offered to return to facility. Family is pending decision to return. 2. The Administrator, DON, Admissions Coordinator, Social Worker, and Business Office Coordinator were in-serviced 1:1 by the [NAME] President of Clinical Services on 4/27/24 on the follow topics. Completed 4/27/24. a. Abuse and Neglect Policy b. Discharge Process Policy: Administrator will ensure a safe discharge in a safe environment with the family representative. Accommodation will be made with the RP prior to discharge during a care plan meeting. The resident will remain in the facility until the family has agreed to the services and care arranged for the discharge. c. Provider Letter/Discharge Appeal Process: A resident will not be discharged pending a discharge appeal. The resident will remain in the facility unless the resident/family agrees to a transfer or safe discharge. 3. The medical Director was notified of the Immediate Jeopardy on 4/27/24 by the Administrator. 4. An ADHOC QAPI meeting was completed with interdisciplinary team on 4/27/24 which included the medical director, Administrator, Director of Nursing, Social Worker, and Business Office Coordinator to discuss the citations and plan of removal. In-services The Administrator and DON initiated the following in-services. Training began 4/27/24 and will be completed 4/28/24. 1. All staff were in-serviced on Abuse/Neglect and Discharge Process, including safe discharge and implementation of discharge plan. All staff not present will not work their next scheduled shift until in-serviced. All new hires will be in-serviced during facility orientation. All agency staff will in be serviced before working their assignment. Monitoring of POR on 4/29/2024 included the following: 2. Observation made on 4/29/2024 at 11:15 a.m. reflected a clean, homelike facility. Residents were up, out of their rooms, dressed and groomed appropriately for the weather. There were no foul odors present or soiled residents. Staff was observed assisting residents in the dining areas, answering call lights in a timely manner, and interacting with residents respectfully. The facility had a sufficient number of staff members to meet residents' needs. No environmental issues noted. 3. In an interview on 4/29/2024 at 11:20 a.m. the Admin stated she had completed 100 percent of in-service training with all staff including Aides and Dietary. The in-services included Abuse/Neglect, Discharge procedures and policy and Resident Property. The Administrator stated she was given one to one inservice by the [NAME] President of Clinical services. She stated knowledge of Abuse Neglect exploitation Policy. The Administrator stated the discharge of Resident #1 should have been accepted by a responsible family member. 4. In an interview on 4/29/2024 at 12:30 p.m. LVN A stated she received in-service education this morning on Abuse Neglect and Discharge Procedures. LVN A stated Abuse Neglect Policy included provisions for providing optimal care to improve a resident's health or living conditions. She stated a Resident must be discharged to a safe and responsible person after discharge planning. 5. In an interview on 4/29/2024 at 12:45 p.m. with Resident #10 stated he had no problems with staff at the facility. He stated they were always polite and kind to him. 6. In an interview on 4/29/2024 at 12:50 p.m. the ADON stated she had received in-service education on Abuse Neglect and Discharge Procedures. The ADON stated knowledge of the Abuse Neglect Policy, she stated staff were tested on knowledge, but she felt familiar with the policy. The ADON stated she received Discharge Planning and Discharge Procedures training, she stated the RP must accept discharged residents and state knowledge of their care needs and medication lists. 7. In an interview on 4/29/2024 at 12:55 p.m. with CNA G stated she had been in serviced on Abuse Neglect and Discharge Procedures. CNA G stated she was inserviced this morning as she had been off work. She stated failing to provide a safe secure environment for a resident would be an example of neglect. She stated the RP must receive a copy of the Discharge Plan and Medication list and understanding of the instructions for care should be checked. 8. In an interview on 4/29/2024 at 1:02 p.m. with Resident # 4, Resident # 7, Resident #8, and Resident #11 stated most staff were nice and that they had no complaints at this time. 9. In an interview on 4/29/2024 at 2:20 p.m. Med Aide A stated she worked the night shift. Med Aide A stated everyone had been in-serviced on Abuse Neglect, Dementia Care, Discharge Procedures, and Customer Service. Med Aide A stated she had worked with the Resident #1 and he took his medications without any problems. The Med Aide A stated knowledge of Abuse Neglect policy, she stated a resident must be provided a safe secure environment and care as needed to avoid neglect. Med Aide A stated discharge planning should include a list of medications, instructions for their administration and a daily schedule. 10. In an interview on 4/30/2024 at 3:38 p.m. the Admin stated she had spoken to the family of Resident #1 today (4/30/2024) and they were still considering their options. She stated the family was still appealing Resident #1's discharge and there was a hearing scheduled for 5/29/24, she stated she was notified of the hearing date today. 11. Record review of facility's abuse and neglect policy revealed the policy included the key components of screening, training, prevention, identification, investigation, protection and reporting alleged incidents of abuse, neglect, and exploitation/misappropriation. 12. Record review of facility's discharge policy revealed the policy included key components of the discharge process. On 4/30/2024 at 4:05 p.m., the Admin was informed the (IJ) Immediate Jeopardy was removed. While the (IJ) Immediate Jeopardy was removed on 4/30/2024 at 4:05 p.m., the facility remained out of compliance at a scope of isolated and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Based on interview and record review the facility failed to obtain timely laboratory services to meet the needs of 1 of 4 residents reviewed for laboratory services. (Resident #3) The facility failed to obtain laboratory values as ordered on [DATE]. Resident #3's laboratory blood draw specimen became useless after an extended time and was not redrawn. Resident #3 was hospitalized on [DATE] with diagnoses including sepsis. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 5:10 p.m. While the IJ was removed on [DATE] at 1:45 p.m., the facility remained out of compliance at actual harm with a scope identified as isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for a delay in identifying or diagnosing medical issues. Findings Include: Review of Resident #3's undated face sheet reflected she was a [AGE] year-old female with diagnoses including Alzheimer's, dementia, congestive heart failure and type II diabetes. Resident #3 was discharged on [DATE] to a local hospital. Review of Resident #3's MDS dated [DATE] revealed a BIMS of 3, indicating moderately impaired cognitive functioning. Review of Resident #3's Care Plan updated [DATE] revealed the following focus: infection Pacemaker placement [DATE]. The goal of the focus was written as discomfort or adverse side effects of antibiotic therapy through the review date. The interventions included in the care plan are, Any antibiotic may cause diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions. Monitor q [every] shift for adverse reaction. Observe for possible side effects every shift. Review of Resident #3's Progress Notes revealed on [DATE], Resident #3 was readmitted to the facility after having a pacemaker implanted. Review of Resident #3's E Transfer Form, dated [DATE] revealed at 11 a.m. resident was sent to the hospital emergency room for pacemaker site bleeding. Review of Resident #3's [DATE] TAR revealed on [DATE] an order for standard labs including a CBC, CMP, HgBA1c, lipid evaluation and TSH was ordered by the NP. The 31st contains initials. Review of Resident #3's [DATE] TAR revealed the order was carried over, but all days were blocked off with an X. Review of the Laboratory Results Form for Resident #3 revealed that on [DATE] a blood draw was conducted; specimen was obtained for the laboratory tests ordered. On [DATE] at 3:27 p.m. the laboratory returned results that did not show values for any of the ordered laboratory test. The reason the tests were not performed noted to be Test cancelled due to the age of the specimen. Continued review revealed there were no initials on the form indicating it had been seen by a nurse or that the NP had been notified of the labs not having been completed. Review of the Nurses' Lab Logging Book kept at the nurse's station revealed the front cover of the notebook contains the following: LOG ALL LAB ORDERS YOU RECEIVE INTO THIS BOOK. **6P-6A NURSES: COMPLETE LOG WHEN LAB IS PICKED UP. CHECK DAILY FOR LAB RESULTS **6A-6P NURSES: FOLLOW UP WITH LAB RESULTS. COMPLETE LOG WHEN RESULTS ARE RECEIVED/NOTIFY MD. Review of the book revealed pages titled Lab Audit Forms which contain a section for the nurse to document the date, resident name, labs ordered, whether the order is stat, date collected/picked up, date results received, and MD notification. Resident #3's name was not listed as a resident that had labs or lab orders for the months of October or November. The lab results or initial order were not located in the book. Review of Resident #3's hospital admission records from the local hospital revealed Resident #3 was admitted on [DATE]. On [DATE] Resident #3 was transferred to a larger hospital where the pacemaker had been implanted, for removal, due to a MRSA infection at the pacemaker site and Sepsis. Review of the facility In-services revealed on [DATE] an in-service was provided by ADON/LVN D contains the following: Lab Procedures: When charge nurse receives new lab order, must notify DON/ADONs. A copy of the lab requisition form and the order should be placed in the lab book, located at the nurse's station. At the start of the shift, all nurses are to check the lab portal for results. The DON/ADON will audit the book regularly to ensure all nurses are following the new protocol. All abnormal results must be reported to the NP/MD. By signing you understand the new process and are aware of how to log into new lab portal and obtain results. Interview on [DATE] at 1:50 p.m., RN A revealed when a lab order comes in the nurse's document it in the lab book kept at the nurse's desk. Once they get results, which arrive by fax or you can also check the portal on computer, the Doctor or NP will be notified. RN A stated the nurse will write on the lab or the NP will initial indicating if new orders. RN A stated some labs do take longer than others but there is a lab trouble shooter that works for lab company that the nurse can call. RN A stated she did not know of a negative outcome because of lab values but if ever encountered that situation would send the resident to the emergency room . Interview on [DATE] at 1:56 p.m., LVN B revealed when a nurse gets an order for a lab draw, they put the order in the lab book and when the results come back, they notify the doctor or NP. LVN B stated they put the hard copy into medical records drawer after the nurse signs it and puts the date it was sent to the doctor or NP. If the NP sees the lab in person, she will initial the hard copy. Interview on [DATE] at 11:11 a.m., LVN C revealed the nurses get orders several different ways mostly from the NP and she will give them a written order on an order sheet. We put the order into the computer under the resident that it was ordered for, and it makes the order pop up on the resident's TAR. LVN C stated once on the TAR, it will let the licensed person knows that the order was made, and that lab is going to be drawn, it is a method of keeping track of whether it was done or not, the nurse initials the TAR when it was drawn and puts in the lab book. LVN C stated the orders also go into the lab website, so they will know to come and collect. LVN C stated she put the lab results hard copy into the medical records drawer where medical records will scan it into the residents EHR. LVN C stated that after we have written the items in the lab book, she believes the ADON or someone else audits the entries. LVN C stated that she has worked at the facility 5 or 6 months and has not received training on the use of the lab book, but the other nurses did explain to her how it is to be used. LVN C stated she has not seen a lab returned without being done due to the specimen being too old. Interview on [DATE] at 11:49 a.m. with LVN D, who is also an ADON, revealed they explained to the nurses when they receive an order, they are supposed to log in the lab book so the next nurses know to look for the lab results and can follow-up. LVN D stated the purpose of the lab book is so it can be tracked when drawn and when to watch for results. The nurses also must make sure to put the order into the EHR but when they notify the lab that triggers the order to appears on the EHR. When an order is made the nurse is acknowledging they have seen and have taken the order off to be completed. The ADON stated she does not know anything about Resident #3's lab results other than it was not documented in the book. LVN D stated that all nurses are to be checking the lab book each time they work, that she works the halls occasionally and always looks at the book. Interview on [DATE] at 1:08 p.m. with LVN E revealed she did work Resident #3's hall the day the lab results came in but that does not mean she would have automatically been the one to pick the results up off the fax machine in the medication room. LVN E stated if it were not in the lab book she would not have known to be watching for the results. LVN E stated she did not see those results and if she had she would have notified the NP that the labs were not conducted and would have expected a new order for a new draw. LVN E stated if lab results come in and it was not documented they add it in the lab book to show it was completed. If there is a critical value or the labs show something that needs to be communicated to the NP, they will call her and make a note on the lab that they did so. If it is a lab that can wait till the NP's next visit, she comes several times a week, they will place it in a folder on her door so she will see it next time comes in. LVN E stated she was initially told how to do the lab book from other nurses but thinks that there may have been an in-service about the lab procedures making sure the nurses were doing it correctly. Interview on [DATE] at 12:55 p.m. and on [DATE] at 10:24 a.m. with the facility NP revealed the last order she made for Resident #3 to have labs on ,d+[DATE] were a prophylactic measure because she had just finished antibiotics after the pacemaker procedure and standard labs due to diagnoses. The NP stated that the nurses are to send the results to her or hand them to her when she is in the facility. She stated she did not specifically remember being told or seeing the insufficient sample results but if she had she would have just ordered that new lab be taken. The NP stated she is almost certain she would have been told of the labs because 95% of the time the nurses let her know. She stated if she had given verbal orders the nurse would place the orders in the EHR, but she does not see any orders for a redraw. The NP stated that she does rely heavily on the nurses to keep up with the labs, that she is just one person, and, in this case, it was a total flub up but usually it is not. She stated she does see how it looks like there is not a good system, but the lab was drawn, it was a mix up on the part of the lab that the specimen was too old. The NP stated there has been some issues with this lab company in the past. Interview on [DATE] at 1:23 p.m. with the facility DON revealed she stated that she was not happy with the current lab company they are using, she has looked into changing to another company and spoken to corporate about the amount of time some of the labs take to receive back. She stated the problem is finding a company that has a phlebotomist to make the blood draws. The DON stated she was not aware when this company started that they would be sending labs to Los Angeles for processing unless it is a stat order. She stated when they started with this company in April an in-service was given for the nurses explaining the new process. She and the ADONs monitor the lab book. The DON stated the nurses are notifying the lab when they get an order, but they are not always documenting in the lab book. She stated she was not notified of this lab specimen being too old for Resident #3 but knows that a nurse must have seen the results as the hard copy was put in the drawer for medical records and uploaded to Resident #3's EHR. The DON stated she will be getting with the medical records person to let them know not to upload a lab that does not include a nurse or NP signature. The DON stated there is not a policy and/or procedure on labs or the process. The DON confirmed that the current system for tracking lab values was broken or was not utilized correctly, and the laboratory was not efficient. Interview on [DATE] at 1:44 p.m. with the RCN revealed that she is at the facility to monitor the process of the lab system as of last week. Do have plans in action we are discussing the process that they have been employing. The RNC stated she think for this facility they are going to have to have someone that audits the process daily. In addition, she stated there is no procedure written up, so she is going to type up the procedures for the new floor nurses that start working for the facility. The RNC stated while she has been speaking to the current facility nurses, they were familiar with the process, but they do not always follow the process the same each time. The RCN stated they have had some issues with the lab company and are in the process of getting a different company that is in a nearby city. Interview on [DATE] at 10:57 a.m. with the facility Administrator revealed she was unable to locate a policy specific to the lab process for nurses. She stated her expectation is that nurses follow the physicians' orders, she assumes they are taught this in nursing school, and it is also located in the facility Physician Order policy. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:10 p.m. The facility Administrator, DON, and RCN were notified. The Administrator was provided with the IJ template on [DATE] at 5:10 p.m. The facility plan of removal was accepted on [DATE] at 1:45 p.m. was as follows. Plan of Removal Problem: F770 Laboratory Services Residents Affected: Residents requiring labs have the potential to be affected by deficient practice. Interventions: 1. Resident #3 remains in the hospital as of [DATE]. 2. Director of Nursing contacted the lab as of [DATE] to follow up on why communication was not made sooner for expired specimen and how can it be prevented. Lab rep stated it was an error on their part and the results will be in the next day. DON/designee will monitor labs daily to check portal for results for 4 weeks. 3. Adhock QAPI meeting held with staff and medical director on [DATE] to discuss and address lab findings. 4. DON/designee audited 100% of resident labs to ensure results were reported to NP/MD, completed on [DATE]. No additional abnormal findings were found. 5. DON/designee audited 100% of lab log notifications on [DATE]. No additional abnormal findings were found. 6. DON/designee pulled new order listing report from PCC daily starting [DATE] to ensure no new orders go unaddressed. This is be an ongoing process and will be regularly monitored by DON/designee. 7. DON/designee in-serviced all licensed staff on [DATE] on checking and printing all lab results from portal at start of shift and end of shift for abnormal results. All abnormal labs will be reported to MD immediately. All lab results will be placed in NP/MDs box for review and signature. DON ADON/weekend supervisor will check daily that labs are printed, reviewed, and reported to MD. DON will conduct random audits starting [DATE] and will continue for the next 4 weeks. 8. All licensed staff not inserviced on [DATE] will be inserviced prior to start of shift, completed [DATE]. All licensed new hires will be inserviced on day 1 of orientation by DON/designee. 9. Compliance Nurse inserviced Administrator, DON and ADON on [DATE] on auditing resident labs daily and on checking and printing all lab results from portal at start of the shift for abnormal results. All abnormal labs will be reported to MD. All lab results will be placed in NP/MDs box for review and signature. DON ADON/weekend supervisor will check daily that labs are printed, reviewed, and reported to MD. DON will conduct random audits [DATE] and will continue for the next 4 weeks. 10. Medical Director notified of immediate jeopardy on [DATE]. Monitoring: 1. The DON and/or ADON will monitor the following at least 5 times per week for at least 4 weeks then monthly thereafter: a. Resident orders to ensure that the timing was appropriate (routine pick up or stat) for all lab orders and to ensure the lab was completed timely according to the order. This will be performed by reviewing the 24-hour report in PCC, and then reviewing the documented condition of each resident who had a lab ordered. b. Review the 24-hour report and documentation to ensure any lab order was entered into PCC correctly and ensure that the lab was ordered via the lab service portal. c. Lab results were reported to the physician or nurse practitioner immediately. 2. The DON and/or ADON will ask at least 4 nurses per week for 4 weeks and then quarterly thereafter to ensure compliance. If staff are no able answer questions, DON/designee will re-inservice on the spot until staff fully understand. a. the timing parameters for the current lab service, i.e., non-stat vs stat b. what they would do if there is a delay in obtaining a lab specimen by the lab. c. What they would do if there is a resident change while awaiting the lab service to obtain a specimen. 3. All findings will be reported to QAPI for the next 3 months. The Surveyor monitored the POR on [DATE] as followed: During interviews on [DATE] from 10:16 a.m. - 3:40 p.m. with the Adm, the DON, two RNs and two LVNs revealed they all stated they were in-serviced on lab procedures. The DON reported they are continuing to audit the lab book. Review of an Ad Hoc QAPI Meeting Agenda Summary, dated [DATE], reflected the NP, RCN, ADM, DON, RNs and LVNs were in attendance. Review of an in-service titled Lab Procedures, dated [DATE] and conducted by the DON, reflected staff were educated on the protocol for labs including the nurse that confirms the order must be the nurse documenting on the lab book, each nurse at the beginning of shift checks the lab portal and faxes, results must be reported to MD/NP, nurse documents name, date and time and places in MD/NP box. The ADON and DON to check the lab book regularly. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by : Interview with Adm on [DATE] at 12:10 p.m. revealed they have finished monitoring all lab orders for all residents. They have audited the month of [DATE] and all labs were completed as ordered. The facility has a new process if labs are needed sooner and will use the hospital lab for stat labs. Review of lab book to show 100% completion of audit for labs ordered in November. Review of sampled resident's lab orders, results and notifications revealed no concerns noted. While the IJ was removed on [DATE] at 1:45 p.m., the facility remained out of compliance at a severity level of actual harm that is 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 implement written policies and procedures that prohibited and prevented abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed immediately intervene to ensure Resident #1 was free from abuse. An allegation was reported that Resident #1 had sexual abuse as non-consensual contact of any type with a resident and the facility failed to identify if Resident #1 had the capacity to consent to sexual intercourse, to assess if Resident #1's had the capacity to consent to sexual intercourse, to get consent acknowledged by the RP, limit and enforce the visitation hours, to report the allegation, and the facility failed to protect Resident #1 from potential abuse as the AP was in the facility at the time of allegation was reported. An IJ (Immediate Jeopardy) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:14 p.m. to ADM, the facility remained out of compliance at no actual harm with a potential for more than minimal harm that is not immediate with a scope of isolated, because all staff had not been trained on Abuse/Neglect, denying AP entrance into the facility, tracking visitors entering the facility, and the facility's need to evaluate the effectiveness of the corrective systems. This failure placed Residents at risk for abuse and not being provided a safe environment. Findings Included: Review of Resident #1's face sheet, dated [DATE], reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), and dementia (impaired ability to remember, think, or make decisions). Review of Resident #1's admission MDS, dated [DATE], reflected a BIMS of 01, indicating a severe cognitive impairment. Review of Resident #1's assessments tab, no date, reflected no assessment completed to determine Resident #1's capacity to consent. Review of Resident #2's face sheet, dated [DATE], reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hyperglycemia (too much sugar in blood), mild cognitive impairment, and altered mental status (abnormal state of alertness or awareness). Review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS of 15, indicating an intact cognitive response. Further review of Resident #2's MDS reflected a 0 for hearing indicating adequate-no difficulty in normal conversation, social interaction, listening to TV. Interview on [DATE] at 1:02 p.m., NA A stated at the start of her shift she was made aware that Resident #2 heard Resident #1 having sexual intercourse with the AP. NA A stated that she did not know who the AP was, she did not know his name. NA A stated that the AP would leave sometimes at ten o'clock in the evenings, sometimes in the early mornings. NA A stated that the AP would visit frequently with Resident #1, she stated that she would inquire the identity to nursing staff, although there was no confirmation on the person. NA stated that facility policy is to keep residents free from abuse and neglect and report all allegations to the administrator. Interview on [DATE] at 1:12 p.m., Resident #2 informed CNA D and stated she overheard Resident #1 and the AP having sexual intercourse on [DATE] in the early morning. Resident #2 stated that she is sure Resident #1 said no. Resident #2 stated the AP would come frequently during the afternoons and stay until late at night. Resident #2 stated she did not know the identity of the AP. Resident #2 stated that, I think he (AP) is a pervert. , as AP would come to the facility for Resident #1 in the afternoons and stay until the night hours. Interview on [DATE] at 1:19 p.m., Resident #1 revealed that she is not aware of who is the current, or the previous, President of the United States. Resident #1 stated that she does not know where she is at, the city she is in, but knows that she lives in the state of Texas. Resident #1 stated that she does not know of anyone visiting her recently. Resident #1 stated she is terrible at remembering things. Resident #1 stated that she does not get visited from her family members. Interview on [DATE] at 2:03 p.m., CNA A revealed that she has seen Resident #1's AP. CNA A stated that the AP comes often and has lunch with Resident #1. CNA stated she provides aide to Resident #1 and recalled that sometimes during aide, Resident #1 will cry or when she is turned Resident #1 will cry. CNA A stated that she is unsure if that is Resident #1's RP. CNA A stated that she is not aware of the AP's name. Interview [DATE] at 2:11 p.m., CNA B revealed that she has observed Resident #1's AP at the facility frequently. CNA B stated that she sometimes she chooses to work a double shift and she would see AP stay late at night. CNA B stated she does not know the AP's name. Interview on [DATE] at 2:11 p.m., CNA C stated that she would see the AP occasionally stay until six o'clock in the morning the following day after coming in the afternoon the day before. CNA C stated that she does not know the AP's name or exactly who he is. Interview on ,d+[DATE].2023 at 2:17 p.m., LVN A stated that the male person has been visiting Resident #1 since she admitted to the facility. LVN A revealed that she does not know the AP's name, she stated that it may start with a B. LVN A stated the AP comes around daily. LVN A stated she has not seen him today, but the AP will stay for a long time. LVN A stated that the allegation was brought to her attention to her by LVN B at the morning meeting at approximately 6:00am, in that CNA D was doing her rounds in the overnight shift and Resident #2 woke up from noises and alleged that she overheard Resident #1 having sexual intercourse and that Resident #1 gave consent. LVN A stated that she called the ADM and DON after the morning meeting, and reported the allegation approximately at 6:30 p.m. Interview on [DATE] at 2:30 p.m., the DON stated that the details of the allegation in that Resident #2 reported she heard the AP ask Resident #1 to have sex, and that Resident #1 gave consent, and that Resident #2 heard noises that sounded like pain. The DON further added that Resident #2 recalled the AP asked Resident #1 are you ok?. The DON stated that Resident #1 and the AP have been friends for a long time since Resident #1 has been admitted , they are always sitting together. The DON stated that she cannot think of AP's name, she is unable to recall it. The DON confirmed that it is not Resident #1's family. The DON states that they found out about the allegation today, this morning. The DON stated that if that is a relationship of her (Resident #1) prior to being here, we must respect her wishes. The DON stated that they considered Resident #2's statement as consensual. The DON further stated that they have no other contact information of AP. Interview on [DATE] at 2:35 p.m., the ADM stated that the allegation was reported to her this morning at seven o'clock. The ADM revealed that there is a relationship between Resident #1 and AP, and is unsure of the history, she cannot confirm if Resident #1 and the AP are dating. The ADM stated she informed the RP of the AP this morning by phone call, and she left a voice message, and that AP has been visiting for a long time. The ADM stated that when she spoke to Resident #2 about the allegation this morning, no approximate time, Resident #1 gave consent, and when Resident #1 asked to stop the AP would stop. The ADM asked Resident #2 if she observed anything disrespectful to Resident #1, or if the AP did anything to not follow Resident #1's wishes and if the AP bothers her, Resident #2 responded no. The ADM was not able to recall the AP's name. During the interview the ADM stated that she is going to pull files from the electronic check in station to retrieve the AP's name. The ADM stated she referred to the allegation as consensual. Interview on [DATE] at 3:42 p.m., the ADM stated that this allegation has never been reported before. The ADM stated that visitation policy revealed that visitors can stay after hours, if residents want the visitor to stay after hours and it is not bothering his or her roommates, the visitors they can stay. The ADM revealed that she was able to retrieve the AP's name from its system. The ADM stated, I updated Resident #1's face sheet so his name is listed there. Record review of Resident #1's face sheet revealed update on [DATE] at 3:40 p.m. Interview on [DATE] at 3:46 p.m., RP revealed that Resident #1 is his family member. The RP stated that he was not aware of the AP's frequent visits. The RP stated that no one at the facility informed him of the AP visiting. The RP stated that he is has heard the name of the AP before, although he does not know who the AP is. The RP states he thinks the Resident #1 met the AP when they worked together at a store. The RP revealed that when Resident #1 was in the hospital, the hospital is the only entity that called him and inquired who the AP was, and the hospital wanted confirmation. The RP stated he never trusted the AP, and he did not give consent for the frequent visits. The RP further stated, if I had the authority, I would not consent to any visits from him. The RP reiterated that he does not trust this person and further stated, he (AP) seems a little weird, I (RP) felt like this person wants to get something if Resident #1 died . The RP further stated that he is not aware if Resident #1 and the AP are in an intimate relationship or dating, and further stated that he hopes they are not. The RP stated that assessments were not completed at the time of admit indicating if she can give consent, and that he does not know if Resident #1 can consent to an intimate relationship. Observation and interview on [DATE] at 5:14 p.m., revealed the AP in Resident #1's room, sitting on the chair next to Resident #1's bed. Resident #1 was asleep. The AP stated that his name, and that Resident #1 is his good friend. The AP stated they met at the store, and that they are not coworkers and met randomly. The AP reiterated that they are good friends. The AP stated that he does not provide medical care to Resident #1, and that he comes here often and a lot. The AP stated that he is sometimes alone with her, and sometimes he pushes Resident #1 when she is on her wheelchair around the facility, has lunch, and sits with Resident #1 in the room. The AP stated that he used to go to Resident #1's home and visit her. Interview on [DATE] at 6:42 p.m., the NP stated that it is hard to say if Resident #1 can give consent to sexual intercourse, Resident #1 can have fluctuation in mentation. The NP further stated that places she worked for in the past would have formal assessments to determine this. The NP further stated she would not be able to say if Resident #1 can give consent to having sexual intercourse as she did not perform an assessment on the resident, there was no indication other than today, assessments are not routinely done unless a situation arises. Interview on [DATE] at 6:42 p.m., LVN B revealed she works the 6 a.m. to 6 p.m., and she is on a rotating schedule. LVN B stated she has seen the AP leaving the facility approximately at 2 a.m. or 3 a.m., LVN B further stated she wanted to ask him to leave because Resident #1 cannot rest although she was informed, she had permission to stay. LVN B revealed observations of Resident #1 in that when the AP comes early in the day and Resident #1 will be happy, although at the late hours Resident #1 will become restless, for example Resident #1 will try climbing out of her bed and complain about pain. LVN B revealed observation of Resident #1 being partially undressed, and the AP would be in the room with Resident #1. LVN B revealed she first started noticing these items approximately in February 2023. LVN B stated that she has never seen the AP have intimate encounters with Resident #1 other than rubbing Resident #1's hand, face, or hair in a consoling manner. LVN B stated the events to her knowledge in that, Resident #2 told the allegation to CNA D approximately at 3:40 a.m., it was not documented, in that Resident #2 heard noises behind the curtains and it sounded like it was sexual in nature, Resident #1 was making noises in pain, and that Resident #1 said stop and then later said ok. LVN B stated she reported it to ADON on [DATE] at 7:42 a.m., then later updated her report to 7:20 a.m., LVN B stated that LVN A was also made aware of her suspicions. Interview on [DATE] at 8:07 p.m., CNA D stated that Resident #2 informed her of the allegation approximately on [DATE] at 3:30 a.m. while she was performing her rounds. CNA D recalled the allegation in that Resident #1 consented to sexual intercourse, and that Resident #1 screamed, and the AP left the room. CNA D recalled she informed LVN B. CNA D revealed that she has not observed any sexual intercourse between Resident #1 and the AP. CNA D that the night shift had concerns about the AP staying in the late hours., CNA D stated she wrote a letter to the ADM about the night shifts concerns. CNA D stated that, in the past, she did not know who the AP was and one instance she had to ask him who he was, how are you and Resident #1 related. The AP informed CNA D that they met at the store. The CNA D stated that occasionally she would do rounds, and Resident #1 would have feces all over her, and would pull her covers back and Resident #1's diaper would be off. Interview on [DATE] at 7:39 a.m., the ADM and DON revealed that Resident #1 returned from the hospital and that according to the SANE nurse there were no significant findings. Resident #1 was sent to the hospital on [DATE]. Interview on [DATE] at 8:30 a.m., the ADON stated she was text messaged by LVN B on [DATE] at 7:34 a.m. about the allegation, although she had already been made aware by LVN A at 6:00 a.m., The ADON further stated that she advised LVN A to contact the ADM immediately about the allegation. Interview on [DATE] at 9:16 a.m., ADM revealed on [DATE] as he was being escorted out of the facility, the AP wanted to inform the details of the allegation in that all he was doing was attempting to get Resident #1's gown in place to get comfortable. The ADM further stated that she does not have the letter from the night shift about expressing their concerns. Interview on [DATE] at 11:09 a.m., Resident #1 stated she is doing fine today, although she revealed that she does not recall meeting the Investigator yesterday. Interview on [DATE] at 2:47 p.m., the ADM stated that before Resident #1 was sent to the hospital, she was assessed for pain, the pubic fracture was identified at the hospital. X-rays were completed at the hospital after the SANE. The ADM added that per the SANE nurse there was no evidence of significant injuries, and the report would be sent off for further testing. The ADM further stated that the NP and other clinical staff discussed the pubic ramus fracture (fracture to the bones to the lower pelvis), and determine it was a new injury. The ADM stated she found out about the injury on [DATE] at 8:15 a.m. and reported it as a facility reported incident as an injury of unknown origin to health and human services. Interview on [DATE] at 9:15 a.m., the DON revealed at the entrance conference that Resident #1 and Resident #2 are having a telehealth with NPPS. The DON revealed copies of the progress notes will be supplied. The DON further stated Resident #1 had pain and pain medication was administered this morning. Interview on [DATE] at 9:52 a.m., NP stated that x-rays were reviewed for Resident #1's visit from the hospital and based on the location of pubic fracture she cannot fathom how the injury would be sustained during sexual intercourse. The NP further stated that the pubic bone that was fractured was the sit bones that you would see injured in a fall to the ground in which a resident landed on her buttocks. The NP stated Resident #1 did recently have a fall in which she landed on her buttocks after slipping out of the bed. The NP stated the recent fall would be more likely to cause that type of fracture as opposed to sexual intercourse because the fracture is located on the interior rim of pubic bone. The NP stated Resident #1 had very brittle bones and the osteoporosis (condition when bone strength weakens and is susceptible to fracture) was easily visible in x-rays of Resident #1's ribs. The NP did not think Resident #1 would be limber enough to be in a sexual position that would cause the broken pubic bone. Interview on [DATE] at 10:20 a.m., Resident #2 stated that Resident #1 did cry out in pain when the AP was having sexual intercourse with her. Resident #2 stated the AP would ask permission for sexual intercourse and Resident #1 would say yes, but Resident #1 would cry out in pain and AP would stop. Resident #2 further stated that a little later the AP would ask again and attempt to have sex with Resident #1, but she would cry out in pain and then stop. Resident #2 added that after 5 to 6 times of trying to have sexual intercourse with Resident #1, the AP would stop. Resident #2 stated this was the first time AP attempted to have sex with Resident #1. Interview on [DATE] at 10:45 a.m., the ADM revealed she spoke to the RP and further stated that when the investigations are closed out and if there are no concerns for Resident #1's safety with the AP, the RP would allow continued visits with Resident #1. The ADM explained about a resident's ability to make decisions, stating that Resident #1 can consent to sexual intercourse or Resident #1 can decline to go to the hospital after at will. ADM revealed RP has no medical power of attorney for Resident #1. Interview on [DATE] at 9:04 a.m., NPPS described Resident #1 of having significant dementia, Resident #1 could not recall date of birth, and family's names. NPPS stated she is not able to determine if Resident #1 can consent to sexual intercourse from one psychiatric evaluation alone. Interview on [DATE] at 2:09 p.m., LCSW described Resident #1's memory is as impaired, and is oriented to person but not to time, place, or situation. Resident #1 has impaired judgement related to memory impairment. LCSW was not able to answer if Resident #1 has the capacity to give consent to sexual intercourse as it is beyond her scope of practice, and she does not assess for capacity. Interview on [DATE] at 4:16 p.m., NP stated that she is not able to answer if Resident #1 is able to understand the risks and benefits of sexual behavior., NP stated that Resident #1 needs formal assistance, and explained that the BIMS is not as detailed as a formal assessment. Interview on [DATE] at 4:17 p.m., NPPS stated she does not know if Resident #1 is able to understand the risks and benefits of sexual behavior, Resident #1 has dementia (impaired ability to remember, think, or make decisions), The NPPS further reiterated her previous statement that she is not able to determine if Resident #1 can consent to sexual intercourse from one psychiatric evaluation alone. Interview on [DATE] at 9:39 a.m., the SANE nurse confirmed that she reported the incident to HHSC generating intake #416188. The SANE nurse confirmed she performed the SANE on Resident #1. The SANE nurse stated there were findings on the left back of Resident #1 revealing scratch [NAME], and an abrasion inside of Resident #1's right labia majora (outer folds of the vulva), she added Resident #1 complained of hip pain and orders were made for additional x-rays. The SANE nurse revealed she was not aware of the additional findings of Resident #1's fractured Pubic ramus, she furthered added there are multiple possibilities of sustaining an abrasion in the labia majora, such as scratching or a fingernail causing it, she could not confirm what action could have caused it but confirmed the abrasion had to be from some type of penetration to that area. The SANE nurse stated that Resident #1 was baseline alert and oriented x1, and Resident #1 had memory issues during the exam as Resident #1 could not recall the previous steps of the assessments after it being explained to her. Interview on [DATE] at 10:38 a.m., CNA E revealed proper technique when performing perineal care, proper infection control practices of wearing gloves and PPE. CNA E revealed that nails are to be trimmed at an appropriate length to perform properly quality of care. CNA E stated that she provided care to Resident #1 occasionally and she is aware to gently provide care to Resident #1 and all residents. CNA E recalls performing care to Resident #1 in that there is always a barrier of her gloved hand and designated wipes, and to always be mindful of not scratching Resident #1 or any residents. Interview on [DATE] at 11:10 a.m., CNA A revealed proper technique when performing perineal care, proper infection control practices of wearing gloves and PPE. CNA A revealed that nails are to be trimmed at an appropriate length to perform properly quality of care. CNA A she provides care to Resident #1 and is familiar on the proper steps to be gentle with the Resident #1 when in perineal care and when applying barrier cream. CNA A stated that she has not seen Resident #1 scratch herself in her perineal areas. CNA A states that Resident #1's movements are usually slow. Observation on [DATE] at 11:22 a.m., Resident #1's nails on both hands appear short and not sharp. Record review of Resident #1's advance directive acknowledgement, dated [DATE], revealed RP signed document. Review of incident reports, no date, revealed Resident #1 fall on [DATE] in that she slid off the side of her bed and fell to the floor. No injuries were noted at that time and pain level was 0. Review of Resident #1's hospital records, dated [DATE], revealed x-ray impressions indicating an age-indeterminate left inferior pubic fracture ramus fracture, new from previous CT. Review of Resident #1's physician orders, dated [DATE], revealed Monitor resident for pain every 4 hours. Assess for verbal and non-verbal cues. If resident is having signs or symptoms of pain, medicate with PRN Norco per order. Hold for signs or symptoms of over sedation and notify medical doctor (examples: increased drowsiness, respiratory changes). Review of Resident #1's MAR, no date, revealed Resident #1 received PRN Norco on [DATE] at 8:16 p.m. with a pain level at 7 and [DATE] at 2:48 p.m. with pain level at 6. Resident #1 received 2 doses on [DATE] at 10:00 a.m. and 3:38 p.m. with a pain level of 4 and 5 respectively. On [DATE] Resident#1 received 1 dose at 10:00 a.m. for a pain level of 6. Review of Resident #1's medical forensic assessment report, dated [DATE], revealed Resident #1 alert and oriented x1, unknown for penetration and ejaculation, top hip left buttocks approximately 5 liner abrasions-similar to scratch like appearance new per ADON, bottom left buttock small red circular abrasions with yellow to red bruising surrounding tender to touch new per ADON, and small abrasion to labia majora at about the 10 o'clock position no bleeding noted at the time of exam, and in follow up care DFPS mandatory if abuse suspected-yes. Review of Resident #1's psychiatric evaluation, dated [DATE], revealed a presumptive diagnosis of dementia, disorganized thinking, general appearance, and behavior as confused, orientation x1, intelligence unable to determine, anxious affect, and disorganized thought content. Review of Resident #1's psychosocial evaluation, dated [DATE], revealed impaired memory, cognitive/executive function not intact, and impaired judgement. Review of the facility's abuse and neglect policy, revised [DATE], revealed, Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Definitions 4. Sexual Abuse: non-consensual sexual contact of any type with a resident. C. Prevention 3. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or anise preventionist within 24-hours of complaint. Appropriate notification to state and home office will be the responsibility of the administrator per policy. 4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious bruising of resident, occurrences, patterns, and trends that may constitute abuse. All occurrences of potential abuse or criminal behavior will be investigated by the Abuse Preventionist and/or designee. E. Reporting 1. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect, or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect, or financial exploitation of the elderly and incapacitated persons. 2. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside normal business hours, the Abuse Preventionist or designee will be called. 3. Facility employees must report all allegation of: abuse. Neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter ,d+[DATE] dated [DATE]. a. if the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. b. if the allegation does not involve abuse or serious bodily injury, the report must be made within 2 hours of the allegation. G. Protection The facility will take necessary measures to protect residents and employees from harm during and following an abuse, neglect, exploitation, mistreatment of residents of property investigation. Review of QAPI meeting, no date, completed for the facility's plan of removal-actions taken to remove the immediate jeopardy. An IJ (Immediate Jeopardy) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:14 p.m. to ADM and a Plan of Removal was requested. A Plan of Removal was first submitted by the ADM on [DATE] at 2:24 p.m.pm. The Plan of removal was accepted on [DATE] at 9:00 a.m. Plan of Removal Immediate Plan of Removal The facility submits this Plan of Removal to address the Immediate Jeopardy identified on [DATE]. Identification of Others Affected by Alleged Deficient Practice: All residents have the potential to be affected by this alleged deficient practice. Summary: Per the immediate jeopardy template, the facility failed to ensure the resident was free from abuse. Immediate Action Taken: 12. ADM/DON had alleged perpetrator removed from the facility on [DATE]. 13. The resident who was potentially assaulted was interviewed by ADM/DON for any emotion distress on [DATE]. 14. A head-to-toe assessment was performed on [DATE] by ADON 1 and ADON 2 for the resident who was potentially assaulted. No negative findings noted. 15. On [DATE], resident #1 had recent hospital visit to address the allegation of sexual abuse. 16. Resident 1 had psych service telehealth visit on [DATE] at 9:30 am. Resident 2 had psych service telehealth visit on [DATE] at 10:15 am. Resident 1 and 2 care plan updated as appropriate. 17. The ADM/DON/Social Worker interviewed other interviewable residents regarding any inappropriate behavior from residents or visitors on [DATE]. There were no negative findings found from interviews. To ensure non-interviewable residents are accounted for, skin assessments were performed on [DATE] by DON/ADON/MDS/Treatment Nurse/Charge nurses. There were no negative findings found from the skin assessments. 18. ADM/DON identified 65 residents with cognitive loss after reviewing the MDS' on [DATE]. 19. The ADM/DON/ADON interviewed all staff who have worked in the last 30 days regarding any observations of inappropriate/sexual behavior among resident, employees, visitors. No additional staff had observed or had concerns of inappropriate/sexual behavior. The 1 staff member who was the initial staff member made aware by resident #2, provided statement to ADM after allegation and investigation began on [DATE]. 20. The visitor entry door code has been changed by Maintenance Director on [DATE] so all staff can monitor who enters the facility. Visitors will only be allowed in by ringing doorbell and staff must open to allow entry. Visitors must sign in to include their name and who they are visiting. All facility staff are responsible for screening visitors, to include visitor name and resident visiting, prior to entry. ADM/DON/ADON inserviced all staff on [DATE] regarding new door policy. 21. ADM/DON/ADON inserviced all facility staff on [DATE] regarding visitor policy. 22. The ADM/DON/ADON began in-servicing on [DATE] for all staff. New hires will be inserviced at orientation. Facility does not utilize agency. Volunteers will be required to screen with any facility staff prior to entry. ADM inserviced Volunteers on [DATE] regarding Abuse/Neglect, Visitor Policy, and New Door Policy. On leave staff were in-service over phone by ADM on [DATE]. If staff are not present, they will be in-serviced prior to assuming their duties on their next scheduled shift regarding: o Abuse/Neglect Policy which includes sexual abuse/inappropriateness. Sexual abuse can occur from a resident, staff, or visitor. o If observed or reported: Separate the residents, staff, or visitors immediately. The alleged perpetrator will be asked to leave the facility. The ADM/DON inserviced all staff that the alleged perpetrator was removed from the facility due to a sexual abuse allegation. The in-service included the alleged perpetrator's name with directions to report to the ADM/DON immediately if seen in the facility. Inserviced performed on [DATE] Report any sexual abuse/inappropriateness to the administrator and DON immediately either in person or by speaking with them on the phone, including weekends. Law enforcement will be notified by ADM/DON immediately upon being made aware of sexual abuse allegation. If a resident is identified to request a sexual relationship, a care plan meeting will be initiated by the Social Service Director to determine the ability to consent. Care plan meetings will occur upon admission, quarterly, and as needed. The care plan meeting will include the resident, RP, MD, IDT team, and ombudsman. The above mentioned care plan meeting will be held at admission, quarterly, and as needed to discuss anyone who is engaged or intends to engage in sexual activity will be evaluated for the capability to consent to sexual activity. If a resident has a BIMS score of 7 or less (Severely Impaired Cognition) and wishes to engage in sexual activity, they will have a Capacity Worksheet for Psychologists completed to determine

Based on observations, interviews, and record reviews the facility failed to protect residents' rights to be free from sexual abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed immediately intervene to ensure Resident #1 was free from sexual abuse. An allegation was reported that Resident #1 had sexual abuse as non-consensual contact of any type with a resident. Resident #1 did not have a capacity assessment to determine if she was able to provide consent and had a BIMs score of 01 indicating a severe cognitive impairment. The facility failed to protect Resident #1 from potential abuse as the AP was in the facility at the time of allegation was reported. An IJ (Immediate Jeopardy) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:14 p.m. to ADM, the facility remained out of compliance at no actual harm with a potential for more than minimal harm that is not immediate with a scope of isolated. This failure placed Residents at risk for abuse and not being provided a safe environment. Findings Included: Review of Resident #1's face sheet, dated [DATE], reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), and dementia (impaired ability to remember, think, or make decisions). Review of Resident #1's admission MDS, dated [DATE], reflected a BIMS of 01, indicating a severe cognitive impairment. Review of Resident #1's assessments tab, no date, reflected no assessment completed to determine Resident #1's capacity to consent. Review of Resident #2's face sheet, dated [DATE], reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hyperglycemia (too much sugar in blood), mild cognitive impairment, and altered mental status (abnormal state of alertness or awareness). Review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS of 15, indicating an intact cognitive response. Further review of Resident #2's MDS reflected a 0 for hearing indicating adequate-no difficulty in normal conversation, social interaction, listening to TV. Interview on [DATE] at 1:02 p.m., NA A stated at the start of her shift she was made aware that Resident #2 heard Resident #1 having sexual intercourse with the AP. NA A stated that she did not know who the AP was, she did not know his name. NA A stated that the AP would leave sometimes at ten o'clock in the evenings, sometimes in the early mornings. NA A stated that the AP would visit frequently with Resident #1, she stated that she would inquire the identity to nursing staff, although there was no confirmation on the person. NA stated that facility policy is to keep residents free from abuse and neglect and report all allegations to the administrator. Interview on [DATE] at 1:12 p.m., Resident #2 informed CNA D and stated she overheard Resident #1 and the AP having sexual intercourse on [DATE] in the early morning. Resident #2 stated that she is sure Resident #1 said no. Resident #2 stated the AP would come frequently during the afternoons and stay until late at night. Resident #2 stated she did not know the identity of the AP. Resident #2 stated that, I think he (AP) is a pervert. , as AP would come to the facility for Resident #1 in the afternoons and stay until the night hours. Interview on [DATE] at 1:19 p.m., Resident #1 revealed that she is not aware of who is the current, or the previous, President of the United States. Resident #1 stated that she does not know where she is at, the city she is in, but knows that she lives in the state of Texas. Resident #1 stated that she does not know of anyone visiting her recently. Resident #1 stated she is terrible at remembering things. Resident #1 stated that she does not get visited from her family members. Interview on [DATE] at 2:03 p.m., CNA A revealed that she has seen Resident #1's AP. CNA A stated that the AP comes often and has lunch with Resident #1. CNA stated she provides aide to Resident #1 and recalled that sometimes during aide, Resident #1 will cry or when she is turned Resident #1 will cry. CNA A stated that she is unsure if that is Resident #1's RP. CNA A stated that she is not aware of the AP's name. Interview [DATE] at 2:11 p.m., CNA B revealed that she has observed Resident #1's AP at the facility frequently. CNA B stated that she sometimes she chooses to work a double shift and she would see AP stay late at night. CNA B stated she does not know the AP's name. Interview on [DATE] at 2:11 p.m., CNA C stated that she would see the AP occasionally stay until six o'clock in the morning the following day after coming in the afternoon the day before. CNA C stated that she does not know the AP's name or exactly who he is. Interview on ,d+[DATE].2023 at 2:17 p.m., LVN A stated that the male person has been visiting Resident #1 since she admitted to the facility. LVN A revealed that she does not know the AP's name, she stated that it may start with a B. LVN A stated the AP comes around daily. LVN A stated she has not seen him today, but the AP will stay for a long time. LVN A stated that the allegation was brought to her attention to her by LVN B at the morning meeting at approximately 6:00am, in that CNA D was doing her rounds in the overnight shift and Resident #2 woke up from noises and alleged that she overheard Resident #1 having sexual intercourse and that Resident #1 gave consent. LVN A stated that she called the ADM and DON after the morning meeting, and reported the allegation approximately at 6:30 p.m. Interview on [DATE] at 2:30 p.m., the DON stated that the details of the allegation in that Resident #2 reported she heard the AP ask Resident #1 to have sex, and that Resident #1 gave consent, and that Resident #2 heard noises that sounded like pain. The DON further added that Resident #2 recalled the AP asked Resident #1 are you ok?. The DON stated that Resident #1 and the AP have been friends for a long time since Resident #1 has been admitted , they are always sitting together. The DON stated that she cannot think of AP's name, she is unable to recall it. The DON confirmed that it is not Resident #1's family. The DON states that they found out about the allegation today, this morning. The DON stated that if that is a relationship of her (Resident #1) prior to being here, we must respect her wishes. The DON stated that they considered Resident #2's statement as consensual. The DON further stated that they have no other contact information of AP. Interview on [DATE] at 2:35 p.m., the ADM stated that the allegation was reported to her this morning at seven o'clock. The ADM revealed that there is a relationship between Resident #1 and AP, and is unsure of the history, she cannot confirm if Resident #1 and the AP are dating. The ADM stated she informed the RP of the AP this morning by phone call, and she left a voice message, and that AP has been visiting for a long time. The ADM stated that when she spoke to Resident #2 about the allegation this morning, no approximate time, Resident #1 gave consent, and when Resident #1 asked to stop the AP would stop. The ADM asked Resident #2 if she observed anything disrespectful to Resident #1, or if the AP did anything to not follow Resident #1's wishes and if the AP bothers her, Resident #2 responded no. The ADM was not able to recall the AP's name. During the interview the ADM stated that she is going to pull files from the electronic check in station to retrieve the AP's name. The ADM stated she referred to the allegation as consensual. Interview on [DATE] at 3:42 p.m., the ADM stated that this allegation has never been reported before. The ADM stated that visitation policy revealed that visitors can stay after hours, if residents want the visitor to stay after hours and it is not bothering his or her roommates, the visitors they can stay. The ADM revealed that she was able to retrieve the AP's name from its system. The ADM stated, I updated Resident #1's face sheet so his name is listed there. Record review of Resident #1's face sheet revealed update on [DATE] at 3:40 p.m. Interview on [DATE] at 3:46 p.m., RP revealed that Resident #1 is his family member. The RP stated that he was not aware of the AP's frequent visits. The RP stated that no one at the facility informed him of the AP visiting. The RP stated that he is has heard the name of the AP before, although he does not know who the AP is. The RP states he thinks the Resident #1 met the AP when they worked together at a store. The RP revealed that when Resident #1 was in the hospital, the hospital is the only entity that called him and inquired who the AP was, and the hospital wanted confirmation. The RP stated he never trusted the AP, and he did not give consent for the frequent visits. The RP further stated, if I had the authority, I would not consent to any visits from him. The RP reiterated that he does not trust this person and further stated, he (AP) seems a little weird, I (RP) felt like this person wants to get something if Resident #1 died . The RP further stated that he is not aware if Resident #1 and the AP are in an intimate relationship or dating, and further stated that he hopes they are not. The RP stated that assessments were not completed at the time of admit indicating if she can give consent, and that he does not know if Resident #1 can consent to an intimate relationship. Observation and interview on [DATE] at 5:14 p.m., revealed the AP in Resident #1's room, sitting on the chair next to Resident #1's bed. Resident #1 was asleep. The AP stated that his name, and that Resident #1 is his good friend. The AP stated they met at the store, and that they are not coworkers and met randomly. The AP reiterated that they are good friends. The AP stated that he does not provide medical care to Resident #1, and that he comes here often and a lot. The AP stated that he is sometimes alone with her, and sometimes he pushes Resident #1 when she is on her wheelchair around the facility, has lunch, and sits with Resident #1 in the room. The AP stated that he used to go to Resident #1's home and visit her. Interview on [DATE] at 6:42 p.m., the NP stated that it is hard to say if Resident #1 can give consent to sexual intercourse, Resident #1 can have fluctuation in mentation. The NP further stated that places she worked for in the past would have formal assessments to determine this. The NP further stated she would not be able to say if Resident #1 can give consent to having sexual intercourse as she did not perform an assessment on the resident, there was no indication other than today, assessments are not routinely done unless a situation arises. Interview on [DATE] at 6:42 p.m., LVN B revealed she works the 6 a.m. to 6 p.m., and she is on a rotating schedule. LVN B stated she has seen the AP leaving the facility approximately at 2 a.m. or 3 a.m., LVN B further stated she wanted to ask him to leave because Resident #1 cannot rest although she was informed, she had permission to stay. LVN B revealed observations of Resident #1 in that when the AP comes early in the day and Resident #1 will be happy, although at the late hours Resident #1 will become restless, for example Resident #1 will try climbing out of her bed and complain about pain. LVN B revealed observation of Resident #1 being partially undressed, and the AP would be in the room with Resident #1. LVN B revealed she first started noticing these items approximately in February 2023. LVN B stated that she has never seen the AP have intimate encounters with Resident #1 other than rubbing Resident #1's hand, face, or hair in a consoling manner. LVN B stated the events to her knowledge in that, Resident #2 told the allegation to CNA D approximately at 3:40 a.m., it was not documented, in that Resident #2 heard noises behind the curtains and it sounded like it was sexual in nature, Resident #1 was making noises in pain, and that Resident #1 said stop and then later said ok. LVN B stated she reported it to ADON on [DATE] at 7:42 a.m., then later updated her report to 7:20 a.m., LVN B stated that LVN A was also made aware of her suspicions. Interview on [DATE] at 8:07 p.m., CNA D stated that Resident #2 informed her of the allegation approximately on [DATE] at 3:30 a.m. while she was performing her rounds. CNA D recalled the allegation in that Resident #1 consented to sexual intercourse, and that Resident #1 screamed, and the AP left the room. CNA D recalled she informed LVN B. CNA D revealed that she has not observed any sexual intercourse between Resident #1 and the AP. CNA D that the night shift had concerns about the AP staying in the late hours., CNA D stated she wrote a letter to the ADM about the night shifts concerns. CNA D stated that, in the past, she did not know who the AP was and one instance she had to ask him who he was, how are you and Resident #1 related. The AP informed CNA D that they met at the store. The CNA D stated that occasionally she would do rounds, and Resident #1 would have feces all over her, and would pull her covers back and Resident #1's diaper would be off. Interview on [DATE] at 7:39 a.m., the ADM and DON revealed that Resident #1 returned from the hospital and that according to the SANE nurse there were no significant findings. Resident #1 was sent to the hospital on [DATE]. Interview on [DATE] at 8:30 a.m., the ADON stated she was text messaged by LVN B on [DATE] at 7:34 a.m. about the allegation, although she had already been made aware by LVN A at 6:00 a.m., The ADON further stated that she advised LVN A to contact the ADM immediately about the allegation. Interview on [DATE] at 9:16 a.m., ADM revealed on [DATE] as he was being escorted out of the facility, the AP wanted to inform the details of the allegation in that all he was doing was attempting to get Resident #1's gown in place to get comfortable. The ADM further stated that she does not have the letter from the night shift about expressing their concerns. Interview on [DATE] at 11:09 a.m., Resident #1 stated she is doing fine today, although she revealed that she does not recall meeting the Investigator yesterday. Interview on [DATE] at 2:47 p.m., the ADM stated that before Resident #1 was sent to the hospital, she was assessed for pain, the pubic fracture was identified at the hospital. X-rays were completed at the hospital after the SANE. The ADM added that per the SANE nurse there was no evidence of significant injuries, and the report would be sent off for further testing. The ADM further stated that the NP and other clinical staff discussed the pubic ramus fracture (fracture to the bones to the lower pelvis), and determine it was a new injury. The ADM stated she found out about the injury on [DATE] at 8:15 a.m. and reported it as a facility reported incident as an injury of unknown origin to health and human services. Interview on [DATE] at 9:15 a.m., the DON revealed at the entrance conference that Resident #1 and Resident #2 are having a telehealth with NPPS. The DON revealed copies of the progress notes will be supplied. The DON further stated Resident #1 had pain and pain medication was administered this morning. Interview on [DATE] at 9:52 a.m., NP stated that x-rays were reviewed for Resident #1's visit from the hospital and based on the location of pubic fracture she cannot fathom how the injury would be sustained during sexual intercourse. The NP further stated that the pubic bone that was fractured was the sit bones that you would see injured in a fall to the ground in which a resident landed on her buttocks. The NP stated Resident #1 did recently have a fall in which she landed on her buttocks after slipping out of the bed. The NP stated the recent fall would be more likely to cause that type of fracture as opposed to sexual intercourse because the fracture is located on the interior rim of pubic bone. The NP stated Resident #1 had very brittle bones and the osteoporosis (condition when bone strength weakens and is susceptible to fracture) was easily visible in x-rays of Resident #1's ribs. The NP did not think Resident #1 would be limber enough to be in a sexual position that would cause the broken pubic bone. Interview on [DATE] at 10:20 a.m., Resident #2 stated that Resident #1 did cry out in pain when the AP was having sexual intercourse with her. Resident #2 stated the AP would ask permission for sexual intercourse and Resident #1 would say yes, but Resident #1 would cry out in pain and AP would stop. Resident #2 further stated that a little later the AP would ask again and attempt to have sex with Resident #1, but she would cry out in pain and then stop. Resident #2 added that after 5 to 6 times of trying to have sexual intercourse with Resident #1, the AP would stop. Resident #2 stated this was the first time AP attempted to have sex with Resident #1. Interview on [DATE] at 10:45 a.m., the ADM revealed she spoke to the RP and further stated that when the investigations are closed out and if there are no concerns for Resident #1's safety with the AP, the RP would allow continued visits with Resident #1. The ADM explained about a resident's ability to make decisions, stating that Resident #1 can consent to sexual intercourse or Resident #1 can decline to go to the hospital after at will. ADM revealed RP has no medical power of attorney for Resident #1. Interview on [DATE] at 9:04 a.m., NPPS described Resident #1 of having significant dementia, Resident #1 could not recall date of birth, and family's names. NPPS stated she is not able to determine if Resident #1 can consent to sexual intercourse from one psychiatric evaluation alone. Interview on [DATE] at 2:09 p.m., LCSW described Resident #1's memory is as impaired, and is oriented to person but not to time, place, or situation. Resident #1 has impaired judgement related to memory impairment. LCSW was not able to answer if Resident #1 has the capacity to give consent to sexual intercourse as it is beyond her scope of practice, and she does not assess for capacity. Interview on [DATE] at 4:16 p.m., NP stated that she is not able to answer if Resident #1 is able to understand the risks and benefits of sexual behavior., NP stated that Resident #1 needs formal assistance, and explained that the BIMS is not as detailed as a formal assessment. Interview on [DATE] at 4:17 p.m., NPPS stated she does not know if Resident #1 is able to understand the risks and benefits of sexual behavior, Resident #1 has dementia (impaired ability to remember, think, or make decisions), The NPPS further reiterated her previous statement that she is not able to determine if Resident #1 can consent to sexual intercourse from one psychiatric evaluation alone. Interview on [DATE] at 9:39 a.m., the SANE nurse confirmed that she reported the incident to HHSC generating intake #416188. The SANE nurse confirmed she performed the SANE on Resident #1. The SANE nurse stated there were findings on the left back of Resident #1 revealing scratch [NAME], and an abrasion inside of Resident #1's right labia majora (outer folds of the vulva), she added Resident #1 complained of hip pain and orders were made for additional x-rays. The SANE nurse revealed she was not aware of the additional findings of Resident #1's fractured Pubic ramus, she furthered added there are multiple possibilities of sustaining an abrasion in the labia majora, such as scratching or a fingernail causing it, she could not confirm what action could have caused it but confirmed the abrasion had to be from some type of penetration to that area. The SANE nurse stated that Resident #1 was baseline alert and oriented x1, and Resident #1 had memory issues during the exam as Resident #1 could not recall the previous steps of the assessments after it being explained to her. Interview on [DATE] at 10:38 a.m., CNA E revealed proper technique when performing perineal care, proper infection control practices of wearing gloves and PPE. CNA E revealed that nails are to be trimmed at an appropriate length to perform properly quality of care. CNA E stated that she provided care to Resident #1 occasionally and she is aware to gently provide care to Resident #1 and all residents. CNA E recalls performing care to Resident #1 in that there is always a barrier of her gloved hand and designated wipes, and to always be mindful of not scratching Resident #1 or any residents. Interview on [DATE] at 11:10 a.m., CNA A revealed proper technique when performing perineal care, proper infection control practices of wearing gloves and PPE. CNA A revealed that nails are to be trimmed at an appropriate length to perform properly quality of care. CNA A she provides care to Resident #1 and is familiar on the proper steps to be gentle with the Resident #1 when in perineal care and when applying barrier cream. CNA A stated that she has not seen Resident #1 scratch herself in her perineal areas. CNA A states that Resident #1's movements are usually slow. Observation on [DATE] at 11:22 a.m., Resident #1's nails on both hands appear short and not sharp. Record review of Resident #1's advance directive acknowledgement, dated [DATE], revealed RP signed document. Review of incident reports, no date, revealed Resident #1 fall on [DATE] in that she slid off the side of her bed and fell to the floor. No injuries were noted at that time and pain level was 0. Review of Resident #1's hospital records, dated [DATE], revealed x-ray impressions indicating an age-indeterminate left inferior pubic fracture ramus fracture, new from previous CT. Review of Resident #1's physician orders, dated [DATE], revealed Monitor resident for pain every 4 hours. Assess for verbal and non-verbal cues. If resident is having signs or symptoms of pain, medicate with PRN Norco per order. Hold for signs or symptoms of over sedation and notify medical doctor (examples: increased drowsiness, respiratory changes). Review of Resident #1's MAR, no date, revealed Resident #1 received PRN Norco on [DATE] at 8:16 p.m. with a pain level at 7 and [DATE] at 2:48 p.m. with pain level at 6. Resident #1 received 2 doses on [DATE] at 10:00 a.m. and 3:38 p.m. with a pain level of 4 and 5 respectively. On [DATE] Resident#1 received 1 dose at 10:00 a.m. for a pain level of 6. Review of Resident #1's medical forensic assessment report, dated [DATE], revealed Resident #1 alert and oriented x1, unknown for penetration and ejaculation, top hip left buttocks approximately 5 liner abrasions-similar to scratch like appearance new per ADON, bottom left buttock small red circular abrasions with yellow to red bruising surrounding tender to touch new per ADON, and small abrasion to labia majora at about the 10 o'clock position no bleeding noted at the time of exam, and in follow up care DFPS mandatory if abuse suspected-yes. Review of Resident #1's psychiatric evaluation, dated [DATE], revealed a presumptive diagnosis of dementia, disorganized thinking, general appearance, and behavior as confused, orientation x1, intelligence unable to determine, anxious affect, and disorganized thought content. Review of Resident #1's psychosocial evaluation, dated [DATE], revealed impaired memory, cognitive/executive function not intact, and impaired judgement. Review of the facility's abuse and neglect policy, revised [DATE], revealed, Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Definitions 4. Sexual Abuse: non-consensual sexual contact of any type with a resident. C. Prevention 3. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or anise preventionist within 24-hours of complaint. Appropriate notification to state and home office will be the responsibility of the administrator per policy. 4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious bruising of resident, occurrences, patterns, and trends that may constitute abuse. All occurrences of potential abuse or criminal behavior will be investigated by the Abuse Preventionist and/or designee. E. Reporting 1. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect, or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect, or financial exploitation of the elderly and incapacitated persons. 2. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside normal business hours, the Abuse Preventionist or designee will be called. 3. Facility employees must report all allegation of: abuse. Neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter ,d+[DATE] dated [DATE]. a. if the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. b. if the allegation does not involve abuse or serious bodily injury, the report must be made within 2 hours of the allegation. G. Protection The facility will take necessary measures to protect residents and employees from harm during and following an abuse, neglect, exploitation, mistreatment of residents of property investigation. Review of QAPI meeting, no date, completed for the facility's plan of removal-actions taken to remove the immediate jeopardy. An IJ (Immediate Jeopardy) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:14 p.m. to ADM and a Plan of Removal was requested. A Plan of Removal was first submitted by the ADM on [DATE] at 2:24 p.m.pm. The Plan of removal was accepted on [DATE] at 9:00 a.m. Plan of Removal Immediate Plan of Removal The facility submits this Plan of Removal to address the Immediate Jeopardy identified on [DATE]. Identification of Others Affected by Alleged Deficient Practice: All residents have the potential to be affected by this alleged deficient practice. Summary: Per the immediate jeopardy template, the facility failed to ensure the resident was free from abuse. Immediate Action Taken: 1. ADM/DON had alleged perpetrator removed from the facility on [DATE]. 2. The resident who was potentially assaulted was interviewed by ADM/DON for any emotion distress on [DATE]. 3. A head-to-toe assessment was performed on [DATE] by ADON 1 and ADON 2 for the resident who was potentially assaulted. No negative findings noted. 4. On [DATE], resident #1 had recent hospital visit to address the allegation of sexual abuse. 5. Resident 1 had psych service telehealth visit on [DATE] at 9:30 am. Resident 2 had psych service telehealth visit on [DATE] at 10:15 am. Resident 1 and 2 care plan updated as appropriate. 6. The ADM/DON/Social Worker interviewed other interviewable residents regarding any inappropriate behavior from residents or visitors on [DATE]. There were no negative findings found from interviews. To ensure non-interviewable residents are accounted for, skin assessments were performed on [DATE] by DON/ADON/MDS/Treatment Nurse/Charge nurses. There were no negative findings found from the skin assessments. 7. ADM/DON identified 65 residents with cognitive loss after reviewing the MDS' on [DATE]. 8. The ADM/DON/ADON interviewed all staff who have worked in the last 30 days regarding any observations of inappropriate/sexual behavior among resident, employees, visitors. No additional staff had observed or had concerns of inappropriate/sexual behavior. The 1 staff member who was the initial staff member made aware by resident #2, provided statement to ADM after allegation and investigation began on [DATE]. 9. The visitor entry door code has been changed by Maintenance Director on [DATE] so all staff can monitor who enters the facility. Visitors will only be allowed in by ringing doorbell and staff must open to allow entry. Visitors must sign in to include their name and who they are visiting. All facility staff are responsible for screening visitors, to include visitor name and resident visiting, prior to entry. ADM/DON/ADON inserviced all staff on [DATE] regarding new door policy. 10. ADM/DON/ADON inserviced all facility staff on [DATE] regarding visitor policy. 11. The ADM/DON/ADON began in-servicing on [DATE] for all staff. New hires will be inserviced at orientation. Facility does not utilize agency. Volunteers will be required to screen with any facility staff prior to entry. ADM inserviced Volunteers on [DATE] regarding Abuse/Neglect, Visitor Policy, and New Door Policy. On leave staff were in-service over phone by ADM on [DATE]. If staff are not present, they will be in-serviced prior to assuming their duties on their next scheduled shift regarding: o Abuse/Neglect Policy which includes sexual abuse/inappropriateness. Sexual abuse can occur from a resident, staff, or visitor. o If observed or reported: Separate the residents, staff, or visitors immediately. The alleged perpetrator will be asked to leave the facility. The ADM/DON inserviced all staff that the alleged perpetrator was removed from the facility due to a sexual abuse allegation. The in-service included the alleged perpetrator's name with directions to report to the ADM/DON immediately if seen in the facility. Inserviced performed on [DATE] Report any sexual abuse/inappropriateness to the administrator and DON immediately either in person or by speaking with them on the phone, including weekends. Law enforcement will be notified by ADM/DON immediately upon being made aware of sexual abuse allegation. If a resident is identified to request a sexual relationship, a care plan meeting will be initiated by the Social Service Director to determine the ability to consent. Care plan meetings will occur upon admission, quarterly, and as needed. The care plan meeting will include the resident, RP, MD, IDT team, and ombudsman. The above mentioned care plan meeting will be held at admission, quarterly, and as needed to discuss anyone who is engaged or intends to engage in sexual activity will be evaluated for the capability to consent to sexual activity. If a resident has a BIMS score of 7 or less (Severely Impaired Cognition) and wishes to engage in sexual activity, they will have a Capacity Worksheet for Psychologists completed to determine if the resident has the capacity to consent to sexual activity. Facility will reference the current company policy for care plan meetings. Administrator in-serviced all staff on [DATE] to notify the administrator of any potential events immediately. Once informed, a care plan meeting will be scheduled with the resident, RP, MD, and IDT team. Th [TRUNCATED]

Based on observation, record review, and interview, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for one of one residents (Resident #3) reviewed for pain management. The facility failed to ensure Resident #3 was assessed, monitored and received pain medication for wound care provided for an infected left ankle wound and a stage 4 pressure ulcer to the left buttock. This failure could place all residents at risk for unnecessary pain and discomfort. Findings include: Review of the undated face sheet for Resident #3 reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Post-Traumatic Stress Disorder, acute, unspecified open wound of left buttock, Heart Failure, Alcohol Dependence, in remission and Insomnia (difficulty sleeping). Review of the quarterly MDS dated [DATE] for Resident #3 reflected a BIMS should be completed but there was no score. His assessment of cognitive patterns indicated his short-term and long-term memory were ok. He could recall the current season, the location of his own room, staff names and faces, and that he was in a nursing home. He was independent to make decisions regarding tasks of daily life. Review of the care plan dated for Resident #3 reflected Resident has venous stasis ulcer r/t CHF, left medial (inner) ankle. Date initiated 01/19/2022 and revised on 07/25/2022. Give meds as ordered for pain. The resident has a potential for uncontrolled pain. Date initiated 02/24/2022. The resident will not have an interruption in normal activities due to pain. Administer analgesia's as per orders. Give 1/2 hour before treatments or care. The resident has a pressure ulcer left buttock stage 4. Initiated 01/26/2022. Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Interview on 10/25/2022 at 11:37 AM, Resident #3 stated he had a burning pain at night to his left foot. I've asked them (nurses) to talk to the Dr. I'm not sure if they have anything left to give me . Observation and interview on 10/26/2022 at 9:31 AM, the treatment nurse provided wound care for Resident #3. LVN Treatment Nurse stated the wound on his left medial, inner foot was a venous wound, and was infected with the bacteria Pseudomonas and he was started on an antibiotic that day. RN Charge Nurse A was in the resident's room for part of the procedure as was the Regional Compliance Nurse. When the dressing was removed from Resident #3's ankle wound, he groaned and said ooh as if in pain. The LVN Treatment Nurse did not ask him if he was having any pain and did not stop the procedure. She stated he had scheduled pain meds. During wound care to his ankle he stated, Oh my god and was grimacing. She stated his left buttock pressure ulcer was facility acquired and a Stage 4 (deep wound reaching the muscles, ligaments or bones). This is the wound we have to pack a little because there is tunneling. She cleansed the wound with saline, and stated to Resident #3, You're going to feel it. The Treatment Nurse began to pack the narrow diameter wound using a sterile applicator and calcium alginate. Resident #3 was grimacing and groaning when the Treatment Nurse asked if he was ok? He stated, yeah then said, Oh god and groaned as she continued pushing the packing into the wound. He stated, Oh dear as she finished packing the wound tunnel. Interview on 10/26/2022 at 10:04 AM, Resident #3 stated his pain level after wound care on his left foot was about an 8. His buttock wound a 3 to 4 but when she crosses that last tunnel (when packing it) it's a good 8 or 9 (out of 10). I receive Tylenol # 3, which is my scheduled pain med, about 8:30 AM after breakfast. I get nothing before wound care. If I could get something that would be great. I'm ok with a pain level of 4-5. Interview on 10/26/2022 at 10:10 AM, the Treatment Nurse, LVN stated, Normally I would ask if the resident was having any pain, but with having to pack a wound, I definitely should have. I should ask if they need a prn med. When asked if she should inquire about a resident's pain after a procedure she stated, I didn't ask them today. I normally would. Record review of the MAR reflected Resident # 3 received his routine pain medication Tylenol with Codeine #3, 300-30 mg 2 tablets two times a day for osteoarthritis on 10/26/2022 at 8:57 AM. No PRN medications were ordered or noted as given on the MAR for his complaint of his ankle burning during the night. Record review of a order change note for Resident # 3 by the Treatment Nurse, LVN dated 10/26/2022 at 10:53 AM reflected Tylenol with Codeine #3 Tablet 300-30 MG (Acetaminophen-Codeine) *Controlled Drug* Give 2 tablet by mouth every 6 hours as needed for Pain Must be 6 hours between scheduled dose; 3AM or 3PM. Record review of a progress note dated 10/27/2022 at 8:38 AM by the Treatment Nurse, LVN reflected, Note Text: Surveyor stated res reported 8/10 pain level which is effecting his sleep at night. Resident interviewed and assessed by this nurse and res states he has dealt w/pain all of his life and Vistaril is the only medication that has helped with his pain and sleep at night. Spoke w/NP A [NAME] and recieved following new orders; Vistaril 25mg po q hs x 5 days- will re evaluate after duration. Tylenol #3 2 tabs prn q 6 hours- Must be 6 hours from 9 am and 6pm scheduled doses; (3pm, and 3am). Res aware w/new orders. Interview on 10/27/2022 at 8:46 AM, with the Treatment Nurse, LVN stated, Signs and symptoms of pain could be facial grimacing, verbal complaints, groans. I did not hear him say oh god or oh dear, but yes, that would indicate pretty severe pain. He was medicated with Tylenol # 3 at 8:57 AM. I asked him one time if he wanted me to stop and he didn't ask me to. Interview on 10/27/2022 at 8:58 AM, RN Charge Nurse A stated, At least once while I was there he did give out a groan while she was pulling the calcium alginate out of the wound. I would think a moan or groan would indicate around a level 6 on the pain scale. Interview on 10/27/2022 at 9:03 AM, the Regional Compliance Nurse who stated he was in the room for wound care performed on Resident #3 on 10/26/2022. He stated the signs and symptoms of pain would be verbal, groans, tense body language, facial expressions. When (Resident #3) was turned over to do the sacral wound he groaned during the packing of the wound. He was pre-medicated, but he did moan during that time. We did not follow up with him on his pain level after treatment. I didn't see any facial grimacing. I didn't hear him say anything to indicate pain. He did tell us later he's been dealing with pain all his life. He brought that to our attention. Yes, we should check pain levels before starting a procedure. Interview on 10/27/22 at 3:03 PM, with the Admin regarding pain management for Resident #3 stated, My expectation is that if a resident is in pain, stop the treatment and make sure he gets pain medications. Admin was informed Resident #3 said, Oh my god, oh dear and was grimacing and groaning during his wound care treatment. Review of an undated facility Dressing Change Checklist reflected, Determine need to pre-medicate for pain. If necessary, verify pain medication order and allow appropriate time for medication to be effective. Review of a facility Nursing Policy and Procedure Manual 2003, Pain Management, Assessment Scale, revised on 05/25/2016 reflected, Pain is a subjective sensation of discomfort from multiple sensory nerve interactions generated by physical, chemical, biological or psychological stimuli. Complaints of pain will be assessed accordingly by the nurse and effectively managed though prescribed medications, and comfort measures and all available resources of the facility. Goals: resident articulates factors that intensify pain. Resident expresses a feeling of comfort and relief from pain. Procedure: Assess resident's physical symptoms of pain, physical complaints. Have the resident to rate pain on a scale of one to ten with one being the least pain and ten being the worst pain experienced. The nurse may use the pain rating scale when assessing effectiveness of medications and assessing for pain intensity. Talk with the resident about pain and assess for pain relief after interventions. Monitor for effectiveness of pain interventions.

Based on observation, interview and record review the facility failed to ensure residents with pressure sores received necessary treatment and services to promote healing, accurately assess and stage, and once developed, failed to ensure necessary treatment and services to promote healing for one (1) of five (5) residents sampled for pressure sores (Resident #1). · The facility failed to routinely assess Resident #1's Stage II pressure sore on a weekly basis after being initially assessed on 07/12/18, (Resident #1 was on hospice and no longer received care from the wound care physician). · The facility failed to notify the physician of changes to the pressure sore resulting in Resident #1 receiving inappropriate treatment and worsening of the sacral pressure sore to a Stage III pressure sore (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. (MONTH) include undermining and tunneling.) The failure to routinely assess and notify the physician of changes contributed to Resident #1's pressure sore decline and placed the other 12 hospice care residents at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), Osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), and severe pain. Finding Include: Review of Resident #1's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnosis: [REDACTED]. The resident was on hospice care. Review of Resident #1's Comprehensive Care plan with a start date of 08/11/2017 and revised on 03/27/2018 reflected a problem category of pressure ulcer. Potential for alteration in skin integrity related to incontinence, decreased mobility, history of pressure ulcers, fragile skin, alteration in nutrition, cognitive impairment and [MEDICAL CONDITION]. The Comprehensive Care plan also reflected Resident #1 did not have a plan of care for her left/ sacral pressure sore. Review of Resident #1's 30-Day PPS MDS assessment dated [DATE] reflected Resident #1 had a Cognitive Skills for Daily Decision Making score of 3 indicating severe cognitive impairment. Resident #1 was coded to be totally dependent on staff for all ADL's. Resident #1 was coded to be incontinent of bowel and bladder. Resident #1 was coded to have one (1) stage II pressure sore. Review of Resident #1's Acute Care Plan dated 06/05/2018 reflected Resident #1 had a Stage II pressure sore to the sacrum. (No indication of right or left side.) Goal of the plan of care was for skin to remain clean and dry and area will heal over the next 90 days. Approaches included perform treatment per order, if no improvement within two weeks report to M.D .keep .M.D. informed of resident's progress. Review of Resident #1's Physician's Telephone Orders reflected an order dated 06/05/2018 for a Stage II to the right buttock/ sacrum, cleanse with wound cleanser, pat dry, apply hydrogel and cover with dry dressing every day and as needed. Observation on 07/27/2018 at 10:15 AM revealed Resident #1 to receive wound care by LVN A. LVN A gathered her supplies placing them on the wax paper. Resident #1 called out in pain when CNA E turned her to her right side. When LVN A removed the brief from Resident #1 there was no dressing in place. LVN A stated she often found Resident #1's pressure sore dressing off when she came to perform the treatment. Resident #1's pressure sore was located on the left upper buttock/sacral region and was a stage III. The wound bed had yellowish granulated tissue and the edges of the pressure sore were white, macerated, and irregular. (Indicating the pressure sore was too moist and the hydrogel treatment was not an appropriate treatment.) The area measured approximately 4 cm x 4 cm x 0.5 cm. LVN A started cleaning the wound in the center and out. Resident #1 screamed out in pain and moved forward, away from the cleansing. LVN A did not stop nor talk to Resident #1. LVN A cleansed the wound again, then dried, and each time LVN A touched the pressure sore Resident #1 cried out in pain and moved forward. LVN A continued to clean the pressure sore two more times with Resident #1 continuing to cry out in pain and move forward away from LVN A. LVN A placed Resident #1's dressing on the wound and when Resident #1 turned on her back she cried out in pain again. A pillow was placed under her legs to float her feet and she cried again. LVN A stated she usually gave the pain medication after the treatment and the resident was on [MEDICATION NAME] because she was on hospice. LVN A went to the charge nurse on the floor and asked her to give some pain medication. Review of Resident #1's consolidated physician orders [REDACTED]. Review of the facility's Weekly pressure Injury QI Log, dated 07/05/2018 and conducted by the DON reflected Resident #1's right buttock/ sacral pressure sore healed. No other entry was noted for Resident #1 on 07/05/2018. Review of the facility's Weekly pressure Injury QI Log dated 07/12/2018 reflected an entry for Resident #1 for a left buttock Stage II pressure sore that was 3.0 cm x 3.5 cm with no depth measured. Further review of the pressure injury log reflected no other assessments of Resident #1's left buttock pressure sore. Review of Resident #1's Skin Assessment flow sheet- pressure injury reflected that Resident #1 had a sacrum wound (no indication if it was right or left side of the sacrum) with first assessment done by LVN A on 7/13/2018 with no stage indicated and with the measurements of 5 cm x 3.5 cm (depth was left blank) with drainage. Further review of Resident #1's flow sheet reflected a second assessment by LVN A on 07/19/2018 with no stage indicated and with the measurements of 4.0 cm x 3.5 cm with <1.0 depth and drainage. No other assessment was documented on the flow sheet. In an interview on 07/27/2018 at 10:45 AM LVN A stated she does not stage pressure sores but the DON does when she does the weekly skin assessments. LVN A further stated she did not tell the DON about the changes to Resident #1's pressure sore. In an interview on 07/27/2018 at 11:40 AM the DON stated if a resident is on hospice they do not see the wound care doctor for assessment. The DON stated she was responsible for assessing and staging pressure sores for residents on hospice. She stated Resident #1 had a Stage II pressure sore to her right buttock. Stated she missed the assessment. When asked if she expected a pressure sore to be covered at all times she stated yes if the dressing comes off she expects the nurses to replace it. DON was not aware resident had a Stage III pressure sore. The DON further stated she did notify Resident #1's physician when she noted Resident #1's pressure sore on 7/12/2018. In an interview on 07/27/2018 at 11:55 AM the hospice RN stated she was not made aware that Resident #1 had a Stage III pressure sore. The hospice RN stated the hospice doctor would need to be notified of changes for Resident #1. The hospice RN stated the facility should have called and let her know about the pressure sore, so she could get physician orders [REDACTED]. The hospice RN stated the resident had a stage I sheering when she was admitted to hospice (was admitted to hospice on 6/12/18). Review of Resident #1's physician notification fax dated 07/10/2018 reflected the Resident #1's facility physician and family were notified on 07/08/2018. The physician notification did not describe Resident #1's pressure sore, no measurements were provided, nor staging information. The physician notification form, under the weight and skin committee recommendations section, reflected Sacrum clean with normal saline, pat dry, cover with protective dressing and change every day and as needed. On the bottom of the notification form there was no physicians signature and a note that Dr. will sign when returns from out of state. In an interview on 07/27/2018 at 12:45 PM when the DON was asked if the physician notification fax form dated 07/10/2018 provided the physician with enough information to make a treatment decision regarding Resident #1's pressure sore. The DON stated no it did not. In an interview on 07/27/2018 at 1:04 PM the Regional Nurse Consultant (RNC) stated she was in-servicing LVN A regarding assessing pain and the on-call physician was called for orders since Resident #1's physician was on vacation. The RNC stated the current wound care nurse (LVN A) had only been doing wounds for two weeks since the last wound care nurse was fired for not doing her job. The RNC stated she recognized the facility had a problem and stated she in-serviced LVN A to notify the DON if changes to wounds occur so the DON could assess the wounds and treatment can be changed as needed. In an interview on 07/27/2018 at 3:15 PM the RNC stated she assessed Resident #1's left buttock/ sacral pressure sore and it was a Stage III. The RNC stated she had started an action plan so something like this does not happen again. The RNC stated she in serviced the DON on weekly skin assessments, and physician notification. Review of the facility's Action Plan dated 07/27/2018 reflected Resident #1 was assessed and medicated for pain. Resident #1 wound was assessed by the nurse and restaged. The primary doctor was contacted to verify the treatment he wanted ordered for her wound. Wound order protocol reviewed by medical director, wound care doctor and hospice physician, and upon agreement, orders signed. This wound care protocol will be implemented per specific wounds unless different order is specifically written by physician .Audit all physician communication forms regarding wounds to verify they include a precise description of the wound so the physician has all pertinent information needed to prescribe the correct treatment for [REDACTED]. In-service all nursing staff regarding notifying the charge nurse if a resident is noted to be missing a dressing so the nurse can take appropriate action .All residents admitting to hospice will be assessed to ensure the new plan of care is communicated to all nursing staff . In an interview on 07/27/2018 at 3:30 PM the Regional Director of Operations stated he expected the nurses to follow facility policies. Review of Resident #1's physician notification fax dated 07/27/2018 reflected Stage 2 wound noted to left buttocks and right buttocks upper sacrum area reassessed at this time noted with a decline to a stage III, the peri-wound bed noted white and macerated. The wound bed noted white no slough or eschar, new treatment clean with normal saline, apply calcium alginate and cover with a composite dressing . The physician notification was signed by the physician. In an interview on 07/30/2018 at 4:12 PM the facility Physician stated he expected the nursing staff to notify the Hospice Physician when there was a change in a resident's condition. He also stated the resident should be medicated prior to a treatment and the wound care treatment with the resident in pain was not appropriate. Review of the facility's policy Pressure Injuries dated 01/2008 and revised 07/2017 reflected Any time a pressure injury is identified it must be documented on the skin assessment flow sheet for pressure injury. Pressure injuries should be measured weekly .Update the care plan. The physician should be notified, and a treatment order received for each pressure injury .The physician and responsible party should be made aware of the progress or deterioration of the pressure injury . The facility provided CMS-672 reflected 12 hospice care residents.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for one (1) of five (5) residents reviewed for pain management with pressure sores.(Resident #1) Resident #1 was not assessed for pain during wound care resulting in Resident #1 enduring painful pressure sore treatments. The failure to assess pain contributed to Resident #1 enduring a painful pressure sore treatment and placed 9 residents with pressure sores at risk for enduring painful pressure sore treatments. Finding Include: Review of Resident #1's face sheet reflected a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive care plan dated 08/11/2017 reflected a problem category of pain with the goal of the resident not exhibiting signs or symptoms of pain. Approaches include assess my pain each shift and as needed using the appropriate pain scale .complete a pain assessment if symptoms of pain noted/ or upon significant change of condition. Review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 had a Cognitive Skills for Daily Decision Making score of 3 indicating severe cognitive impairment. Resident #1 was coded to be totally dependent on staff for all ADL's. Resident #1 was coded to incontinent of bowel and bladder. Resident #1 was coded to have one (1) stage II pressure sore. Resident #1 was coded to have non-verbal sounds as indicators for pain such as crying, gasping, or moaning as well as vocal complaints of pain. Resident #1 was coded to have pain 3-4 days out of 5 days. Review of Resident #1's consolidated physician orders [REDACTED]. Review of Resident #1's Physician Telephone Orders dated 06/22/2018 reflected an order for [REDACTED]. Observation on 07/27/2018 at 10:15 AM revealed Resident #1 to receive wound care by LVN A. LVN A gathered her supplies placing them on the wax paper. Resident #1 called out in pain when CNA E turned her to her right side. When LVN A removed the brief from Resident #1 there was no dressing in place. LVN A stated she often found Resident #1's pressure sore dressing off when she came to perform the treatment. Resident #1's pressure sore was located on the left upper buttock/sacral region and was a stage III. The wound bed had yellowish granulation tissue and the edges of the pressure sore were white, macerated, and irregular. (Indicating the pressure sore was to moist and the hydrogel treatment was not an appropriate treatment.) The area measured approximately 4 cm x 4 cm x 0.5 cm. LVN A started cleaning the wound in the center and out. Resident #1 screamed out in pain and moved forward, away from the cleansing. LVN A did not stop nor talk to Resident #1. LVN A cleansed the wound again, then dried, and each time LVN A touched the pressure sore Resident #1 cried out in pain and moved forward. LVN A continued to clean the pressure sore two more times with Resident #1 continued to cry out in pain and move forward away from LVN A. LVN A placed Resident #1's dressing on and when Resident #1 turned on her back she cried out in pain again. A pillow was placed under her legs to float her feet and she cried again. LVN A stated she usually gave the pain medication after the treatment and she was on [MEDICATION NAME] because she was on hospice. LVN A went to the charge nurse on the floor and asked her to give some pain medication. Review of Resident #1's MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR further reflected Resident #1 received [MEDICATION NAME] 0.25 ml by mouth by the charge nurse after the pressure sore treatment was done. Observation on 07/27/2018 at 11:15 AM revealed Resident #1 in bed on her right side sleeping without signs or symptoms of pain. Review of the facility's Weekly pressure Injury QI Log dated 07/12/2018 reflected an entry for Resident #1 for a left buttock Stage II pressure sore that was 3.0 cm x 3.5 cm with no depth measured. In an interview on 07/27/2018 at 11:40 AM the DON stated she expected the nurses to assess resident for pain prior to and during wound care treatments. In an interview on 07/27/2018 at 11:55 AM the hospice RN stated she was not made aware of the fact that Resident #1 had a Stage III pressure sore. The hospice RN stated the hospice doctor would need to be notified of changes for Resident #1. The hospice RN stated she was appalled that the facility did not call her and would most defiantly expect the nurses to assess the resident for pain prior to treatments and medicate her. In an interview on 07/27/2018 at 1:04 PM the Regional Nurse Consultant (RNC) stated she was in-servicing LVN A regarding assessing pain. The RNC stated the current wound care nurse (LVN A) had only been doing wounds for two weeks since the last wound care nurse was fired for not doing her job. The RNC stated she recognized the facility had a problem and further stated she had in-serviced LVN A. Review of the facility's Action Plan dated 07/27/2018 reflected Resident #1 was assessed and medicated for pain. treatments being performed .In-service all nursing staff including the treatment nurse on assessing and medicating for pain prior to any treatments being performed . In an interview on 07/27/2018 at 3:30 PM the Regional Director of Operations stated he expected the nurses to follow facility policies. In an interview on 07/30/2018 at 4:12 PM the facility Physician stated he expected the nursing staff to notify the Hospice Doctor when there was a change in a resident's condition. He also stated the resident should be medicated prior to a treatment and the wound care treatment with the resident in pain was not appropriate. In an interview on 07/27/2018 at 4:30 PM the RNC stated the facility did not have a policy regarding pain with pressure sores that the facility nurses should practice professional standards. The facility provided CMS-672 reflected 9 residents with pressure sores.

Based on observations, record reviews, and interviews, the facility failed to make prompt efforts to resolve resident grievances for 1 of 21 residents reviewed for abuse. The facility failed to make prompt efforts to resolve a grievance Resident #16 filed regarding verbal abuse from Housekeeper A.Housekeeper A confronted and yelled at Resident 16 after the resident filed grievances about Housekeeper A. Housekeeper A returned to Resident #16's door the following day and intimidated Resident #16 by belittling and laughing at her to CNA J and CMA K knowing Resident #16 was looking at her and could hear Housekeeper A as she spoke. The facility failed to initiate an investigation or report to a State Agency allegations of abuse invovling Resident #16 from Housekeeper A. Housekeeper A was allowed to continue working regular assigned hours. Resident #16 had episodes of crying and became fearful when leaving her room. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 11/17/17. While the IJ was removed on 11/18/17, the facility remained out of compliance with at actual harm with a scope identified as pattern. These failures resulted in psychological harm for Resident #16. Findings include: Review of Resident #16's Face Sheet reflected a [AGE] year old female, reflected the following Diagnoses: [REDACTED]. Review of Resident #16's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 15 indicating the resident was cognitively intact. Review of Resident #16's Care Plan dated 06/14/2017, reflected she required assistance for Activities of Daily Living (ADLs) with one person assist. Review of a grievance report written by the Administrator dated 11/15/2017 for Resident #16 reflected an incident of Housekeeper A being disrespectful, mean tone towards the resident. Housekeeper A was moved off the hallway and assigned to another hallway. Housekeeper A was verbally counseled on how to and how not to engage with residents. The report reflected no further action. Review of a statement written by Housekeeper A dated 11/17/17 reflected I got into a confrontation with (Resident #16). In the confrontation I asked (Resident #16) did she want another grievance form to write another one on me. I told her (the resident) I was obligated (sic) to talk to whoever I wanted. In an interview on 11/16/2017 at 11:50 AM Resident #16 stated Yesterday I was sitting in the chair. (Housekeeper A) came in yelling, she knew I filed grievances, and said to me You going to write some more? The resident stated she went into the hallway crying and looking to speak to the Administrator. The resident stated in the past she would ask the Housekeeper A for more bags and paper towels and the Housekeeper A would have an attitude or just stare at her. Resident #16 further stated that, after the first confrontation, the Housekeeper A came back the next day and stood in her doorway talking about her to CNA J and CMA K. She also stated she felt scared and didn't want the Housekeeper A near her. Resident #16 stated she could hear the Housekeeper A outside of her room laughing at her. Resident #16 stated she wrote grievances against the Housekeeper A about cleaning but she didn't expect the Housekeeper A to confront her about the grievances or make her feel bad. Resident #16 stated she told the Administrator but felt the Administrator thought she was a liar. Resident #16 stated she was crying as she told the Administrator about the verbal abuse. The resident further stated the Administrator told her to go back to her room. In an interview on 11/16/2017 at 2:15 PM, CNA J stated that on 11/17/2017 she spoke with Resident #16 who had told her that Housekeeper A had come up to her and stated If you want to file grievances then file them adding many mean comments, and yelling. The CNA further stated the Resident told the Administrator of her allegation the Administrator sided with the Housekeeper A. CNA J further stated, earlier that day, she witnessed Housekeeper A , had walked over to 100 hall when she wasn't working the 100 hall and stated to them I'm no longer on this hall and it's because of your girl. CNA J stated the Housekeeper A said all this in front of Resident #16's door. Resident #16 later then stated to CNA J that the Housekeeper A had looked at her while she talked in front of her door and the Housekeeper A shouldn't be around her or on the hall. CNA J stated she stayed with Resident #16 until Housekeeper A left the 100 hall because the Resident appeared fearful around Housekeeper A. CNA J continued to state the Housekeeper A would skip cleaning rooms. The Housekeeper A also didn't clean another resident's toilet or room when she had bowel movements. The DON was notified of the Housekeeper A not cleaning properly. CNA J further stated the Housekeeper A had a tone like she was better than the residents. CNA J further stated she did not report the conversation to the Administration because she thought the Administrator was already aware of the issue. In an interview on 11/16/2017 at 2:15 PM, CMA K stated Resident #16 told her about the incident and had been crying. CMA K further stated she told the resident to talk to the Administrator. CMA K stated when more than one resident came to her with issues with the Housekeeper A she told them to tell the abuse coordinator (Administrator). CMA K also stated she told the residents Don't tell me. I am just the med aide. Tell the Administrator about the allegations. CMA K then stated she had told Housekeeper A about her language. She stated the Housekeeper A had even been smart to the Housekeeper A manager. CMA K stated she witnessed Housekeeper A being hostile because she was being moved to another hall after Resident #16 wrote the grievance. CMA K further stated she did not report what she had learned to the Administrator because she was under the impression he was already aware of the issue. In an interview on 11/16/2017 at 2:15 PM, Housekeeper A stated I told (Resident #16) I know you filed a grievance but did you tell the good in your grievance? She then stated she told Resident #16 I'm obligated (sic) to talk to who I want to talk to. The Housekeeper A stated she went to hall 100 the previous day where Resident #16 room was located. The Housekeeper asked Resident #16 why she filed a second grievance and Resident #16 said it's because I was talking to a nurse in front of her door. The Housekeeper A stated she has been mad at her for not cleaning the floor. In an interview on 11/17/2017 at 8:40 AM, the DON stated Resident #16 did not cry a lot and is not typically crying. She stated the only part of the incident she was aware of is on 11/15/2017 when she seen the resident upset running over to the phone. She also stated she then told the Administrator to look at the upset resident on the phone and the Administrator nodded to her that he knew about her being upset. She stated she saw Resident #16 visibly upset and on the phone at the nurses station but never got to interview the resident about why she was upset. The DON stated confronting residents about grievances is inappropriate. The DON also stated she understood how this is a situation to report to the state. In an interview on 11/17/2017 at 8:56 AM, the Administrator stated he never called Resident #16 a liar and he never told her to go back to her room. He was unaware of the Housekeeper A saying things to the resident in an aggressive manner because he had not yet spoken to the resident. He was aware Resident #16 was distraught, and he stated he didn't interview her (Resident #16). He stated he was aware the Housekeeper A confronted the resident about the grievance and could have possibly talked to her in a disrespectful manner. The Administrator further stated he completed Resident #16's second grievance report regarding Housekeeper A's second visit to the resident's room. The Administrator stated he did not immediately intervene because Resident was distraut. The Administrator stated my mistake was not reporting the allegation of verbal abuse when it happened. He then stated we will discuss all allegations from this point forward to make sure that things that are reportable are reported. The Administrator further stated that he was familiar with the facility's abuse policy. In an interview on 11/17/2017 at 8:56 AM, the SW stated she would report anything that the resident told her about being hurt. She further stated I would report it to the Administrator because he is the abuse coordinator. The SW stated she (Housekeeper A) shouldn't have spoken to the resident about the grievance and the Housekeeper A shouldn't have gone back to the resident's area. She further stated I would report if a resident or family reported to me or staff they were spoken ugly to. In an interview on 11/17/2017 at 9:43 AM, Resident #16's son stated when he came to the facility he saw Resident #16 was shaking. He stated he did not know how the Housekeeper A knew about the grievance that led her to confront Resident #16. He stated the Administrator automatically believed the Housekeeper A over Resident #16. He further stated that it was completely out of character for Resident #16 to cry for two days. In the past, before the incident occurred, he stated she was always wanting to meet new people, smiling, and laughing. However, after the incident, Resident #16 was scared and would only go to the activity room and back to her room, he didn't understand why the cleaning staff confronted Resident #16. He continued to state Resident #16 was in her room and didn't want to come out of her room because, on the previous day, the Housekeeper A had been in front of her room laughing at her, Resident #16 didn't want to go to the Thanksgiving event. The complainant stated the facility was trying to make it seem like it didn't happen but it did and could be worse next time. He further stated Resident #16 feared reprisal from the facility staff. Policy and Procedure for Grievance-Voicing and Resolution dated 03/2017 reflected: Policy It is the policy of this nursing home that staff will promptly attempt to resolve grievances the resident may have, including those, which involve the behavior of others. They will be able to voice grievances without fear of reprisal or discrimination. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents and other concerns regarding their stay. Procedure 1. The home will inform each resident upon admission and at least annually of their right to voice grievances in treatment, violation of rights, care, management of funds, or lost clothing without fear of reprisal or retaliation. 2. The Grievance Official will be the Administrator who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigation by the facility; maintain the confidentiality of all information associated with grievances, for state and federal agencies as necessary in light of specific allegations. 3. Grievance will be written on the home's (Grievance/ Complaint Report Form). 4. The home will address each grievance in a reasonable time frame and as necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated. 5. The home will accept grievances in written and verbal form. 6. The home will keep a (Grievance/ Complaint Log) outlining each grievance/ complaint and the disposition of the complaint. 7. The home will provide acknowledgement of grievance to person who filed complaint. 8. Home will upon resolution of grievance, follow-up in a timely manner to assure that resolution has been successful. 9. Complete Grievance/ Concern Forms will be filed together in binder (one binder per year) and separated by month. 10. Maintain evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision. Review of the policy Abuse-Reportable Events dated 07/2017, reflected a policy: It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/ event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. Definitions Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm, pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct. Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly though words or physical action which causes or could cause mental/ psychological, or physical abuse, including corporal punishment, involuntary seclusion, or any other actions within this definition. Mental/psychological abuse: Mistreatment within the definition of abuse means to inappropriately treat or exploit a resident, not resulting in physical harm, including, but not limited to, humiliation, harassment, threats of punishment, deprivation, or intimidation. Verbal abuse: The use of oral, written, or gestured language that includes disparaging derogatory terms to a resident or within the resident's hearing distance, regardless of the resident's age, ability to comprehend, or disability. Procedure 1. Screening 2. Training 3. Prevention 4. Identification 5. Investigation When an employee becomes aware of an allegation or suspicion of abuse the employee should immediately the allegation or suspicion to the charge nurse on the unit on which the resident resides immediately. The abuse coordinator will: Review all aspects of the investigation as soon as possible. Ensure that all reports are complete and appropriate authorities have been notified including the notification of the local law enforcement related to any crimes against a resident. Complete the investigation and direct any disciplinary action required. Complete the State Provider Investigation Report (5 day report). Review corrective action(s). Inform the resident or his/her representative of the findings of the investigation and corrective action taken 6. Protection All residents will be immediately protected from harm. All allegations involving staff will necessitate suspension without pay, pending investigation. If the allegations is substantiated, the employee will be terminated immediately without pay retroactive to the date of removal from employment. 7. Reporting All alleged allegations of abuse will be reported to the appropriate state agency and to all other agencies as required by regulation. After investigation, administration will analyze the occurrence to determine what changes, if any, are needed for the policies and procedures to prevent further occurrences. In an interview on 11/17/2017 at 10:30 AM the Survey Team Leader informed the Administrator, DON, Regional Administrative Director and Regional Nurse that an Immediate Jeopardy was identified due to the above failures. In an interview on 11/17/2017 at 11:58 AM, Resident #16 stated she got her nails done and went back to her room, she didn't normally stay in her room but since the incident she didn't feel safe in the facility. In an interview on 11/17/2017 at 2:13 PM, the SW stated she should talk to the resident and find out what's going on and report to the abuse coordinator. The SW was unaware of the allegations. The SW stated she knew that after abuse were alleged she needed to talk with the complaining resident to see if she was comfortable and what she could do to help. In an interview on 11/17/2017 at 4:02 PM, the SW stated she had not yet assessed the resident after the abuse allegation. She was unaware about the allegations until I informed her. She stated she only spoke to the resident the day before about her old roommate. The SW was in a care plan meeting and couldn't assess Resident #16 earlier because she had been watching a movie. In an interview on 11/17/2017 at 4:15 PM The Regional Operations Director stated When the Administrator saw the resident crying and upset that should've been his cue to investigate. In an interview on 11/17/2017 at 4:30 PM, the SW stated to the Survey Team Coordinator that she had just assessed the resident at that time and Resident #16 was a little scared and distressed. The facility's third draft of the Plan of Removal was accepted on 11/17/2017 at 5:15 PM in the presence of the facility's Administrator. The plan included: Facility: Lampstand Nursing & Rehab Plan of Removal # 3 Date:11/17/2017 Problem: Failure to recognize potentially abusive situations, conduct a thorough investigation and reporting allegations of abuse and/or neglect. Goal: The facility will recognize potentially abusive situations and thoroughly investigate and report all allegations of abuse and/or neglect. Goal Date: 11/18/2017 *Approaches: Responsible Person(s) **Monitoring: Facility Medical Director was notified that an Immediate Jeopardy was called and was notified on 11/17/2017 at noon. Regional Nurse Consultant 11/16/ 2017 at 3:45 PM the RDO was made aware that the Administrator failed in identify the allegation of abuse from 11/15/2017. The employee in question was immediately suspended on 11/16/2017 at 4:00 PM. Resident # 16 mental state was assessed by Social Worker on 11/17/2017 at 4:33 PM and the resident states that she is a little scared, and a little afraid. Resident # 16 will continue to be monitored every day until she returns to her emotional baseline. Monitoring will be conducted by the social worker or licensed nurse. Resident #16 will be referred to psychological services prior to 11/22/2017 Regional Director of Operations Social Worker / Licensed Nurse Safe surveys were started at 5:00 PM on 11/16/2017 for alert residents and Residents on the hallway 1 and 2 (where the alleged perpetrator worked) had safe surveys conducted and will be completed by 11/17/17 by 5:00 PM. No further issues identified. Ambassadors 80% of facility staff will be educated on reporting any allegations of abuse or neglect to the facility abuse coordinator by 11/17/2017 at 2:fpm. 100% staff will be educated on reporting any allegations of abuse or neglect to the facility abuse coordinator by 11/18/2017 at 9:00 AM. Regional Director of Operations, Regional Nurse Consultant, Administrator RDO & RNC 80% of facility staff will be educated on who to call if they call the facility abuse coordinator and that person does not answer or if they do not receive a call back within 30 minutes. Completed by 11/17/2017 at 2:00 PM. 100% of staff will be educated on who to call if they call the facility abuse coordinator and that person does not answer or if they do not receive a call back within 30 minutes by 11/18/2017 at 9:00 AM. RDO. RNC RDO & RNC Facility Administrator received 1 on 1 education on identifying potentially abusive situation, thoroughly investigating and the guidelines for reporting potential abuse and/or neglect allegations. Will be completed by 11/17/2017 completed at 4:30 PM. Backup abuse coordinators are the RDO and RNC. RDO 80% of facility staff will be educated on who the backup abuse coordinator is if the facility abuse coordinator is not available by 11/17/2017 at 2:00 PM. 100% of staff will be educated on who the backup abuse coordinator is if the facility abuse coordinator is not available by 11/18/2017 at 9:00 AM. The backup abuse coordinators will be the RDO and the, RN RNC. RDO, RNC, ADM The facility Administrator has been educated that he must call the RDO and the RNC within 1 hour for any allegations of abuse and/or neglect. 1 on 1 education was done on 11/16/2017 at 6:00 PM. RDO The facility has posted notifications throughout the building on who should be contacted if the facility abuse coordinator is not available or does not respond. Done 11/16/2017 at 9:30 PM. ADMIN The RDO and RNC will review the grievance book bi-monthly when they are in the facility to ensure that all allegations of abuse and/or neglect have been handled appropriately. RDO, RNC Ambassadors will conduct random interviews during their daily rounding regarding staff treatment of [REDACTED]. Rounding sheets will be turned into the Administrator daily for review. ADMIN, RDO The manager on duty for the weekend will conduct random interviews with residents regarding staff treatment of [REDACTED]. Any manager that receives a negative comment from a resident will call the abuse coordinator within 30 minutes of being made aware. Training will be completed by 11/17/2017 at 11:45 AM. Department Managers Any negative comments noted on the daily rounding sheets by the Administrator will require a phone call to the RDO and RNC for discussion within 1 hour of being made aware. In-service done 11/16/2017 at 6:00 PM. RDO Daily Ambassador rounding sheets will be kept in a notebook in the Administrator's office starting 11/17/2017. Daily Ambassador rounding sheets will be reviewed bi-monthly by the RDO and RNC during their routine visits. ADMIN, RDO, RNC RNC will educate all Ambassadors on how to conduct a safe survey with a resident who has a negative comment to identify potential abuse and/or neglect allegations. In-service was completed at noon on 11/17/2017. RNC *Steps taken to achieve the Goal The survey team monitored the Plan of Removal from 11/17/2017 to 11/18/17 as follows: 1. Observed in-Services as listed in the Plan of Correction. 2. Interviewed staff members regarding their knowledge of in-service subject matter as well as general knowledge of Abuse/Neglect policies and procedures. 3. Interviewed Residents regarding their general feeling of safety and if they had any concerns regarding any staff members. 4. Reviewed in-service sign in logs as well as written material distributed during the in-services. On 11/18/17 at 3:10 PM the Facility Administrator, was informed the IJ was removed. However, the facility remained out of compliance actual harm with a scope as pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. Resident #16 was listed as a curernt resident according to the facility roster.

Based on observations, record reviews, and interviews, the facility failed to ensure the residents had the right to be free from verbal and mental abuse for 1 of 21 residents reviewed for abuse. Housekeeper A confronted and yelled at Resident #16 after the resident filed grievances about Housekeeper A. Housekeeper A returned to Resident #16's door the following day and intimidated Resident #16 by belittling and laughing at her to CNA J and CMA K knowing Resident #16 was looking at her and could hear Housekeeper A as she spoke. The facility failed to intiate an investigation or suspend Housekeeper A after an allegation of abuse had been made against the housekeeper resulting in further abuse to Resident #16. Resident #16 had episodes of crying and became fearful when leaving her room. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 11/17/17. While the IJ was removed on 11/18/17, the facility remained out of compliance of actual harm with a scope identified as pattern. These failures resulted in psychological harm for Resident #16. Findings include: Review of Resident #16's Face Sheet reflected a [AGE] year old female, reflected the following Diagnoses: [REDACTED]. Review of Resident #16's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 15 indicating the resident was cognitively intact. Review of Resident #16's Care Plan dated 06/14/2017, reflected she required assistance for Activities of Daily Living (ADLs) with one person assist. Review of a grievance report written by the Administrator dated 11/15/2017 for Resident #16 reflected an incident of Housekeeper A being disrespectful, mean tone towards the resident. Housekeeper A was moved off the hallway and assigned to another hallway. Housekeeper A was verbally counseled on how to and how not to engage with residents. The report reflected no further action. Review of a statement written by Housekeeper A dated 11/17/17 reflected I got into a confrontation with (Resident #16). In the confrontation I asked (Resident #16) did she want another grievance form to write another one on me. I told her (the resident) I was obligated (sic) to talk to whoever I wanted. In an interview on 11/16/2017 at 11:50 AM Resident #16 stated Yesterday I was sitting in the chair. (Housekeeper A) came in yelling, she knew I filed grievances, and said to me You going to write some more? The resident stated she went into the hallway crying and looking to speak to the Administrator. The resident stated in the past she would ask the Housekeeper A for more bags and paper towels and the Housekeeper A would have an attitude or just stare at her. Resident #16 further stated that, after the first confrontation, the Housekeeper A came back the next day and stood in her doorway talking about her to CNA J and CMA K. She also stated she felt scared and didn't want the Housekeeper A near her. Resident #16 stated she could hear the Housekeeper A outside of her room laughing at her. Resident #16 stated she wrote grievances against the Housekeeper A about cleaning but she didn't expect the Housekeeper A to confront her about the grievances or make her feel bad. Resident #16 stated she told the Administrator but felt the Administrator thought she was a liar. Resident #16 stated she was crying as she told the Administrator about the verbal abuse. The resident further stated the Administrator told her to go back to her room. In an interview on 11/16/2017 at 2:15 PM, CNA J stated that on 11/17/2017 she spoke with Resident #16 who had told her that Housekeeper A had come up to her and stated If you want to file grievances then file them adding many mean comments, and yelling. The CNA further stated the Resident told the Administrator of her allegation the Administrator sided with the Housekeeper A. CNA J further stated, earlier that day, she witnessed Housekeeper A , had walked over to 100 hall when she wasn't working the 100 hall and stated to them I'm no longer on this hall and it's because of your girl. CNA J stated the Housekeeper A said all this in front of Resident #16's door. Resident #16 later then stated to CNA J that the Housekeeper A had looked at her while she talked in front of her door and the Housekeeper A shouldn't be around her or on the hall. CNA J stated she stayed with Resident #16 until Housekeeper A left the 100 hall because the Resident appeared fearful around Housekeeper A. CNA J continued to state the Housekeeper A would skip cleaning rooms. The Housekeeper A also didn't clean another resident's toilet or room when she had bowel movements. The DON was notified of the Housekeeper A not cleaning properly. CNA J further stated the Housekeeper A had a tone like she was better than the residents. CNA J further stated she did not report the conversation to the Administration because she thought the Administrator was already aware of the issue. In an interview on 11/16/2017 at 2:15 PM, CMA K stated Resident #16 told her about the incident and had been crying. CMA K further stated she told the resident to talk to the Administrator. CMA K stated when more than one resident came to her with issues with the Housekeeper A she told them to tell the abuse coordinator (Administrator). CMA K also stated she told the residents Don't tell me. I am just the med aide. Tell the Administrator about the allegations. CMA K then stated she had told Housekeeper A about her language. She stated the Housekeeper A had even been smart to the Housekeeper A manager. CMA K stated she witnessed Housekeeper A being hostile because she was being moved to another hall after Resident #16 wrote the grievance. CMA K further stated she did not report what she had learned to the Administrator because she was under the impression he was already aware of the issue. In an interview on 11/16/2017 at 2:15 PM, Housekeeper A stated I told (Resident #16) I know you filed a grievance but did you tell the good in your grievance? She then stated she told Resident #16 I'm obligated (sic) to talk to who I want to talk to. The Housekeeper A stated she went to hall 100 the previous day where Resident #16 room was located. The Housekeeper asked Resident #16 why she filed a second grievance and Resident #16 said it's because I was talking to a nurse in front of her door. The Housekeeper A stated she has been mad at her for not cleaning the floor. In an interview on 11/17/2017 at 8:40 AM, the DON stated Resident #16 did not cry a lot and is not typically crying. She stated the only part of the incident she was aware of is on 11/15/2017 when she seen the resident upset running over to the phone. She also stated she then told the Administrator to look at the upset resident on the phone and the Administrator nodded to her that he knew about her being upset. She stated she saw Resident #16 visibly upset and on the phone at the nurses station but never got to interview the resident about why she was upset. The DON stated confronting residents about grievances is inappropriate. The DON also stated she understood how this is a situation to report to the state. In an interview on 11/17/2017 at 8:56 AM, the Administrator stated he never called Resident #16 a liar and he never told her to go back to her room. He was unaware of the Housekeeper A saying things to the resident in an aggressive manner because he had not yet spoken to the resident. He was aware Resident #16 was distraught, and he stated he didn't interview her (Resident #16). He stated he was aware the Housekeeper A confronted the resident about the grievance and could have possibly talked to her in a disrespectful manner. The Administrator stated he did not immediately intervene because Resident was distraut. The Administrator stated my mistake was not reporting the allegation of verbal abuse when it happened. He then stated we will discuss all allegations from this point forward to make sure that things that are reportable are reported. The Administrator further stated that he was familiar with the facility's abuse policy. In an interview on 11/17/2017 at 8:56 AM, the SW stated she would report anything that the resident told her about being hurt. She further stated I would report it to the Administrator because he is the abuse coordinator. The SW stated she (Housekeeper A) shouldn't have spoken to the resident about the grievance and the Housekeeper A shouldn't have gone back to the resident's area. She further stated I would report if a resident or family reported to me or staff they were spoken ugly to. In an interview on 11/17/2017 at 9:43 AM, Resident #16's son stated when he came to the facility he saw Resident #16 was shaking. He stated he did not know how the Housekeeper A knew about the grievance that led her to confront Resident #16. He stated the Administrator automatically believed the Housekeeper A over Resident #16. He further stated that it was completely out of character for Resident #16 to cry for two days. In the past, before the incident occurred, he stated she was always wanting to meet new people, smiling, and laughing. However, after the incident, Resident #16 was scared and would only go to the activity room and back to her room, he didn't understand why the cleaning staff confronted Resident #16. He continued to state Resident #16 was in her room and didn't want to come out of her room because, on the previous day, the Housekeeper A had been in front of her room laughing at her, Resident #16 didn't want to go to the Thanksgiving event. The complainant stated the facility was trying to make it seem like it didn't happen but it did and could be worse next time. He further stated Resident #16 feared reprisal from the facility staff. In an interview on 11/17/2017 at 9:59 AM, The Housekeeper A manager stated the Housekeeper A had stated in the past I'll clean when I feel like it The housekeeping supervisor wasn't aware of the incidents that occurred with Resident #16. She was only aware of Resident #16's grievance of the Housekeeper A not cleaning her room. Review of the policy Abuse-Reportable Events dated 07/2017, reflected a policy: It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/ event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. Definitions Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm, pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct. Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly though words or physical action which causes or could cause mental/ psychological, or physical abuse, including corporal punishment, involuntary seclusion, or any other actions within this definition. Mental/psychological abuse: Mistreatment within the definition of abuse means to inappropriately treat or exploit a resident, not resulting in physical harm, including, but not limited to, humiliation, harassment, threats of punishment, deprivation, or intimidation. Verbal abuse: The use of oral, written, or gestured language that includes disparaging derogatory terms to a resident or within the resident's hearing distance, regardless of the resident's age, ability to comprehend, or disability. Procedure 1. Screening 2. Training 3. Prevention 4. Identification 5. Investigation When an employee becomes aware of an allegation or suspicion of abuse the employee should immediately the allegation or suspicion to the charge nurse on the unit on which the resident resides immediately. The abuse coordinator will: Review all aspects of the investigation as soon as possible. Ensure that all reports are complete and appropriate authorities have been notified including the notification of the local law enforcement related to any crimes against a resident. Complete the investigation and direct any disciplinary action required. Complete the State Provider Investigation Report (5 day report). Review corrective action(s). Inform the resident or his/her representative of the findings of the investigation and corrective action taken 6. Protection All residents will be immediately protected from harm. All allegations involving staff will necessitate suspension without pay, pending investigation. If the allegations is substantiated, the employee will be terminated immediately without pay retroactive to the date of removal from employment. 7. Reporting All alleged allegations of abuse will be reported to the appropriate state agency and to all other agencies as required by regulation. After investigation, administration will analyze the occurrence to determine what changes, if any, are needed for the policies and procedures to prevent further occurrences. In an interview on 11/17/2017 at 10:30 AM the Survey Team Leader informed the Administrator, DON, Regional Administrative Director and Regional Nurse that an Immediate Jeopardy was identified due to the above failures. In an interview on 11/17/2017 at 11:58 AM, Resident #16 stated she got her nails done and went back to her room, she didn't normally stay in her room but since the incident she didn't feel safe in the facility. In an interview on 11/17/2017 at 2:13 PM, the SW stated she should talk to the resident and find out what's going on and report to the abuse coordinator. The SW was unaware of the allegations. The SW stated she knew that after abuse were alleged she needed to talk with the complaining resident to see if she was comfortable and what she could do to help. In an interview on 11/17/2017 at 4:02 PM, the SW stated she had not yet assessed the resident after the abuse allegation. She was unaware about the allegations until I informed her. She stated she only spoke to the resident the day before about her old roommate. The SW was in a care plan meeting and couldn't assess Resident #16 earlier because she had been watching a movie. In an interview on 11/17/2017 at 4:15 PM The Regional Operations Director stated When the Administrator saw the resident crying and upset that should've been his cue to investigate. In an interview on 11/17/2017 at 4:30 PM, the SW stated to the Survey Team Coordinator that she had just assessed the resident at that time and Resident #16 was a little scared and distressed. The facility's third draft of the Plan of Removal was accepted on 11/17/2017 at 5:15 PM in the presence of the facility's Administrator. The plan included: Facility: Lampstand Nursing & Rehab Plan of Removal # 3 Date:11/17/2017 Problem: Failure to recognize potentially abusive situations, conduct a thorough investigation and reporting allegations of abuse and/or neglect. Goal: The facility will recognize potentially abusive situations and thoroughly investigate and report all allegations of abuse and/or neglect. Goal Date: 11/18/2017 *Approaches: Responsible Person(s) **Monitoring: Facility Medical Director was notified that an Immediate Jeopardy was called and was notified on 11/17/2017 at noon. Regional Nurse Consultant 11/16/ 2017 at 3:45 PM the RDO was made aware that the Administrator failed in identify the allegation of abuse from 11/15/2017. The employee in question was immediately suspended on 11/16/2017 at 4:00 PM. Resident # 16 mental state was assessed by Social Worker on 11/17/2017 at 4:33 PM and the resident states that she is a little scared, and a little afraid. Resident # 16 will continue to be monitored every day until she returns to her emotional baseline. Monitoring will be conducted by the social worker or licensed nurse. Resident #16 will be referred to psychological services prior to 11/22/2017 Regional Director of Operations Social Worker / Licensed Nurse Safe surveys were started at 5:00 PM on 11/16/2017 for alert residents and Residents on the hallway 1 and 2 (where the alleged perpetrator worked) had safe surveys conducted and will be completed by 11/17/17 by 5:00 PM. No further issues identified. Ambassadors 80% of facility staff will be educated on reporting any allegations of abuse or neglect to the facility abuse coordinator by 11/17/2017 at 2:fpm. 100% staff will be educated on reporting any allegations of abuse or neglect to the facility abuse coordinator by 11/18/2017 at 9:00 AM. Regional Director of Operations, Regional Nurse Consultant, Administrator RDO & RNC 80% of facility staff will be educated on who to call if they call the facility abuse coordinator and that person does not answer or if they do not receive a call back within 30 minutes. Completed by 11/17/2017 at 2:00 PM. 100% of staff will be educated on who to call if they call the facility abuse coordinator and that person does not answer or if they do not receive a call back within 30 minutes by 11/18/2017 at 9:00 AM. RDO. RNC RDO & RNC Facility Administrator received 1 on 1 education on identifying potentially abusive situation, thoroughly investigating and the guidelines for reporting potential abuse and/or neglect allegations. Will be completed by 11/17/2017 completed at 4:30 PM. Backup abuse coordinators are the RDO and RNC. RDO 80% of facility staff will be educated on who the backup abuse coordinator is if the facility abuse coordinator is not available by 11/17/2017 at 2:00 PM. 100% of staff will be educated on who the backup abuse coordinator is if the facility abuse coordinator is not available by 11/18/2017 at 9:00 AM. The backup abuse coordinators will be the RDO and the, RN RNC. RDO, RNC, ADM The facility Administrator has been educated that he must call the RDO and the RNC within 1 hour for any allegations of abuse and/or neglect. 1 on 1 education was done on 11/16/2017 at 6:00 PM. RDO The facility has posted notifications throughout the building on who should be contacted if the facility abuse coordinator is not available or does not respond. Done 11/16/2017 at 9:30 PM. ADMIN The RDO and RNC will review the grievance book bi-monthly when they are in the facility to ensure that all allegations of abuse and/or neglect have been handled appropriately. RDO, RNC Ambassadors will conduct random interviews during their daily rounding regarding staff treatment of [REDACTED]. Rounding sheets will be turned into the Administrator daily for review. ADMIN, RDO The manager on duty for the weekend will conduct random interviews with residents regarding staff treatment of [REDACTED]. Any manager that receives a negative comment from a resident will call the abuse coordinator within 30 minutes of being made aware. Training will be completed by 11/17/2017 at 11:45 AM. Department Managers Any negative comments noted on the daily rounding sheets by the Administrator will require a phone call to the RDO and RNC for discussion within 1 hour of being made aware. In-service done 11/16/2017 at 6:00 PM. RDO Daily Ambassador rounding sheets will be kept in a notebook in the Administrator's office starting 11/17/2017. Daily Ambassador rounding sheets will be reviewed bi-monthly by the RDO and RNC during their routine visits. ADMIN, RDO, RNC RNC will educate all Ambassadors on how to conduct a safe survey with a resident who has a negative comment to identify potential abuse and/or neglect allegations. In-service was completed at noon on 11/17/2017. RNC *Steps taken to achieve the Goal The survey team monitored the Plan of Removal from 11/17/2017 to 11/18/17 as follows: 1. Observed in-Services as listed in the Plan of Correction. 2. Interviewed staff members regarding their knowledge of in-service subject matter as well as general knowledge of Abuse/Neglect policies and procedures. 3. Interviewed Residents regarding their general feeling of safety and if they had any concerns regarding any staff members. 4. Reviewed in-service sign in logs as well as written material distributed during the in-services. On 11/18/17 at 3:10 PM the Facility Administrator, was informed the IJ was removed. However, the facility remained out of compliance of acutal harm with a scope as pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. Resident #16 was listed as a curernt resident according to the facility roster.

Based on observations, record reviews, and interviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse for one (1) of 21 residents reviewed for abuse (Resident #16). The facility staff, CNA J and CMA K failed to immediately report witnessed verbal abuse towards Resident #16 from Housekeeper A when Housekeeper A confronted and yelled at Resident #6 after the resident filed grievances about Housekeeper A. The facility Administrator,who was the Abuse Coordinator, failed to investigate and suspend Housekeeper A after Resident #16 reported an allegation of verbal abuse from Housekeeper A. Housekeeper A was allowed to continue regular work duties. The Admistrator failed to report that allegation of verbal abuse involving Resident #16 to a State Agency. Housekeeper A started intimidating Resident #16 after her grievance was filed on 11/15/2017 and the Administrator was aware. Resident #16 had episodes of crying and became fearful when leaving her room. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 11/17/17. While the IJ was removed on 11/18/17, the facility remained out of compliance of actual harm with a scope identified as pattern. These failures resulted in psychological harm for Resident #16. Findings include: Review of the policy Abuse-Reportable Events dated 07/2017, reflected a policy: It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/ event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. Definitions Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm, pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct. Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly though words or physical action which causes or could cause mental/ psychological, or physical abuse, including corporal punishment, involuntary seclusion, or any other actions within this definition. Mental/psychological abuse: Mistreatment within the definition of abuse means to inappropriately treat or exploit a resident, not resulting in physical harm, including, but not limited to, humiliation, harassment, threats of punishment, deprivation, or intimidation. Verbal abuse: The use of oral, written, or gestured language that includes disparaging derogatory terms to a resident or within the resident's hearing distance, regardless of the resident's age, ability to comprehend, or disability. Procedure 1. Screening 2. Training 3. Prevention 4. Identification 5. Investigation When an employee becomes aware of an allegation or suspicion of abuse the employee should immediately the allegation or suspicion to the charge nurse on the unit on which the resident resides immediately. The abuse coordinator will: Review all aspects of the investigation as soon as possible. Ensure that all reports are complete and appropriate authorities have been notified including the notification of the local law enforcement related to any crimes against a resident. Complete the investigation and direct any disciplinary action required. Complete the State Provider Investigation Report (5 day report). Review corrective action(s). Inform the resident or his/her representative of the findings of the investigation and corrective action taken 6. Protection All residents will be immediately protected from harm. All allegations involving staff will necessitate suspension without pay, pending investigation. If the allegations is substantiated, the employee will be terminated immediately without pay retroactive to the date of removal from employment. 7. Reporting All alleged allegations of abuse will be reported to the appropriate state agency and to all other agencies as required by regulation. After investigation, administration will analyze the occurrence to determine what changes, if any, are needed for the policies and procedures to prevent further occurrences. Review of Resident #16's Face Sheet reflected a [AGE] year old female, reflected the following Diagnoses: [REDACTED]. Review of Resident #16's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 15 indicating the resident was cognitively intact. Review of Resident #16's Care Plan dated 06/14/2017, reflected she required assistance for Activities of Daily Living (ADLs) with one person assist. Review of a grievance report written by the Administrator dated 11/15/2017 for Resident #16 reflected an incident of Housekeeper A being disrespectful, mean tone towards the resident. Housekeeper A was moved off the hallway and assigned to another hallway. Housekeeper A was verbally counseled on how to and how not to engage with residents. The report reflected no further action. Review of a statement written by Housekeeper A dated 11/17/17 reflected I got into a confrontation with (Resident #16). In the confrontation I asked (Resident #16) did she want another grievance form to write another one on me. I told her (the resident) I was obligated (sic) to talk to whoever I wanted. In an interview on 11/16/2017 at 11:50 AM Resident #16 stated Yesterday I was sitting in the chair. (Housekeeper A) came in yelling, she knew I filed grievances, and said to me You going to write some more? The resident stated she went into the hallway crying and looking to speak to the Administrator. The resident stated in the past she would ask the Housekeeper A for more bags and paper towels and the Housekeeper A would have an attitude or just stare at her. Resident #16 further stated that, after the first confrontation, the Housekeeper A came back the next day and stood in her doorway talking about her to CNA J and CMA K. She also stated she felt scared and didn't want the Housekeeper A near her. Resident #16 stated she could hear the Housekeeper A outside of her room laughing at her. Resident #16 stated she wrote grievances against the Housekeeper A about cleaning but she didn't expect the Housekeeper A to confront her about the grievances or make her feel bad. Resident #16 stated she told the Administrator but felt the Administrator thought she was a liar. Resident #16 stated she was crying as she told the Administrator about the verbal abuse. The resident further stated the Administrator told her to go back to her room. In an interview on 11/16/2017 at 2:15 PM, CNA J stated that on 11/17/2017 she spoke with Resident #16 who had told her that Housekeeper A had come up to her and stated If you want to file grievances then file them adding many mean comments, and yelling. The CNA further stated the Resident told the Administrator of her allegation the Administrator sided with the Housekeeper A. CNA J further stated, earlier that day, she witnessed Housekeeper A , had walked over to 100 hall when she wasn't working the 100 hall and stated to them I'm no longer on this hall and it's because of your girl. CNA J stated the Housekeeper A said all this in front of Resident #16's door. Resident #16 later then stated to CNA J that the Housekeeper A had looked at her while she talked in front of her door and the Housekeeper A shouldn't be around her or on the hall. CNA J stated she stayed with Resident #16 until Housekeeper A left the 100 hall because the Resident appeared fearful around Housekeeper A. CNA J continued to state the Housekeeper A would skip cleaning rooms. The Housekeeper A also didn't clean another resident's toilet or room when she had bowel movements. The DON was notified of the Housekeeper A not cleaning properly. CNA J further stated the Housekeeper A had a tone like she was better than the residents. CNA J further stated she did not report the conversation to the Administration because she thought the Administrator was already aware of the issue. In an interview on 11/16/2017 at 2:15 PM, CMA K stated Resident #16 told her about the incident and had been crying. CMA K further stated she told the resident to talk to the Administrator. CMA K stated when more than one resident came to her with issues with the Housekeeper A she told them to tell the abuse coordinator (Administrator). CMA K also stated she told the residents Don't tell me. I am just the med aide. Tell the Administrator about the allegations. CMA K then stated she had told Housekeeper A about her language. She stated the Housekeeper A had even been smart to the Housekeeper A manager. CMA K stated she witnessed Housekeeper A being hostile because she was being moved to another hall after Resident #16 wrote the grievance. CMA K further stated she did not report what she had learned to the Administrator because she was under the impression he was already aware of the issue. In an interview on 11/16/2017 at 2:15 PM, Housekeeper A stated I told (Resident #16) I know you filed a grievance but did you tell the good in your grievance? She then stated she told Resident #16 I'm obligated (sic) to talk to who I want to talk to. The Housekeeper A stated she went to hall 100 the previous day where Resident #16 room was located. The Housekeeper asked Resident #16 why she filed a second grievance and Resident #16 said it's because I was talking to a nurse in front of her door. The Housekeeper A stated she has been mad at her for not cleaning the floor. In an interview on 11/17/2017 at 8:40 AM, the DON stated Resident #16 did not cry a lot and is not typically crying. She stated the only part of the incident she was aware of is on 11/15/2017 when she seen the resident upset running over to the phone. She also stated she then told the Administrator to look at the upset resident on the phone and the Administrator nodded to her that he knew about her being upset. She stated she saw Resident #16 visibly upset and on the phone at the nurses station but never got to interview the resident about why she was upset. The DON stated confronting residents about grievances is inappropriate. The DON also stated she understood how this is a situation to report to the state. In an interview on 11/17/2017 at 8:56 AM, the Administrator stated he never called Resident #16 a liar and he never told her to go back to her room. He was unaware of the Housekeeper A saying things to the resident in an aggressive manner because he had not yet spoken to the resident. He was aware Resident #16 was distraught, and he stated he didn't interview her (Resident #16). He stated he was aware the Housekeeper A confronted the resident about the grievance and could have possibly talked to her in a disrespectful manner. The Administrator stated he did not immediately intervene because Resident was distraut. The Administrator stated my mistake was not reporting the allegation of verbal abuse when it happened. He then stated we will discuss all allegations from this point forward to make sure that things that are reportable are reported. The Administrator further stated that he was familiar with the faciulity's abuse policy. In an interview on 11/17/2017 at 8:56 AM, the SW stated she would report anything that the resident told her about being hurt. She further stated I would report it to the Administrator because he is the abuse coordinator. The SW stated she (Housekeeper A) shouldn't have spoken to the resident about the grievance and the Housekeeper A shouldn't have gone back to the resident's area. She further stated I would report if a resident or family reported to me or staff they were spoken ugly to. In an interview on 11/17/2017 at 9:43 AM, Resident #16's son stated when he came to the facility he saw Resident #16 was shaking. He stated he did not know how the Housekeeper A knew about the grievance that led her to confront Resident #16. He stated the Administrator automatically believed the Housekeeper A over Resident #16. He further stated that it was completely out of character for Resident #16 to cry for two days. In the past, before the incident occurred, he stated she was always wanting to meet new people, smiling, and laughing. However, after the incident, Resident #16 was scared and would only go to the activity room and back to her room, he didn't understand why the cleaning staff confronted Resident #16. He continued to state Resident #16 was in her room and didn't want to come out of her room because, on the previous day, the Housekeeper A had been in front of her room laughing at her, Resident #16 didn't want to go to the Thanksgiving event. The complainant stated the facility was trying to make it seem like it didn't happen but it did and could be worse next time. He further stated Resident #16 feared reprisal from the facility staff. In an interview on 11/17/2017 at 9:59 AM, The Housekeeper A manager stated the Housekeeper A had stated in the past I'll clean when I feel like it The housekeeping supervisor wasn't aware of the incidents that occurred with Resident #16. She was only aware of Resident #16's grievance of the Housekeeper A not cleaning her room. In an interview on 11/17/2017 at 10:30 AM the Survey Team Leader informed the Administrator, DON, Regional Administrative Director and Regional Nurse that an Immediate Jeopardy was identified due to the above failures. In an interview on 11/17/2017 at 11:58 AM, Resident #16 stated she got her nails done and went back to her room, she didn't normally stay in her room but since the incident she didn't feel safe in the facility. In an interview on 11/17/2017 at 2:13 PM, the SW stated she should talk to the resident and find out what's going on and report to the abuse coordinator. The SW was unaware of the allegations. The SW stated she knew that after abuse were alleged she needed to talk with the complaining resident to see if she was comfortable and what she could do to help. In an interview on 11/17/2017 at 4:02 PM, the SW stated she had not yet assessed the resident after the abuse allegation. She was unaware about the allegations until I informed her. She stated she only spoke to the resident the day before about her old roommate. The SW was in a care plan meeting and couldn't assess Resident #16 earlier because she had been watching a movie. In an interview on 11/17/2017 at 4:15 PM The Regional Operations Director stated When the Administrator saw the resident crying and upset that should've been his cue to investigate. In an interview on 11/17/2017 at 4:30 PM, the SW stated to the Survey Team Coordinator that she had just assessed the resident at that time and Resident #16 was a little scared and distressed. The facility's third draft of the Plan of Removal was accepted on 11/17/2017 at 5:15 PM in the presence of the facility's Administrator. The plan included: Facility: Lampstand Nursing & Rehab Plan of Removal # 3 Date:11/17/2017 Problem: Failure to recognize potentially abusive situations, conduct a thorough investigation and reporting allegations of abuse and/or neglect. Goal: The facility will recognize potentially abusive situations and thoroughly investigate and report all allegations of abuse and/or neglect. Goal Date: 11/18/2017 *Approaches: Responsible Person(s) **Monitoring: Facility Medical Director was notified that an Immediate Jeopardy was called and was notified on 11/17/2017 at noon. Regional Nurse Consultant 11/16/ 2017 at 3:45 PM the RDO was made aware that the Administrator failed in identify the allegation of abuse from 11/15/2017. The employee in question was immediately suspended on 11/16/2017 at 4:00PM. Resident # 16 mental state was assessed by Social Worker on 11/17/2017 at 4:33PM and the resident states that she is a little scared, and a little afraid. Resident # 16 will continue to be monitored every day until she returns to her emotional baseline. Monitoring will be conducted by the social worker or licensed nurse. Resident #16 will be referred to psychological services prior to 11/22/2017 Regional Director of Operations Social Worker / Licensed Nurse Safe surveys were started at 5:00PM on 11/16/2017 for alert residents and Residents on the hallway 1and 2 (where the alleged perpetrator worked) had safe surveys conducted and will be completed by 11/17/17 by 5:00PM. No further issues identified. Ambassadors 80% of facility staff will be educated on reporting any allegations of abuse or neglect to the facility abuse coordinator by 11/17/2017 at 2:00pm. 100% staff will be educated on reporting any allegations of abuse or neglect to the facility abuse coordinator by 11/18/2017 at 9:00AM. Regional Director of Operations, Regional Nurse Consultant, Administrator RDO & RNC 80% of facility staff will be educated on who to call if they call the facility abuse coordinator and that person does not answer or if they do not receive a call back within 30 minutes. Completed by 11/17/2017 at 2:00PM. 100% of staff will be educated on who to call if they call the facility abuse coordinator and that person does not answer or if they do not receive a call back within 30 minutes by 11/18/2017 at 9:00AM. RDO. RNC RDO & RNC Facility Administrator received 1 on 1 education on identifying potentially abusive situation, thoroughly investigating and the guidelines for reporting potential abuse and/or neglect allegations. Will be completed by 11/17/2017 completed at 4:30PM. Backup abuse coordinators are the RDO and RNC. RDO 80% of facility staff will be educated on who the backup abuse coordinator is if the facility abuse coordinator is not available by 11/17/2017 at 2:00PM. 100% of staff will be educated on who the backup abuse coordinator is if the facility abuse coordinator is not available by 11/18/2017 at 9:00 AM. The backup abuse coordinators will be the RDO and the, RN RNC. RDO, RNC, ADM The facility Administrator has been educated that he must call the RDO and the RNC within 1 hour for any allegations of abuse and/or neglect. 1 on 1 education was done on 11/16/2017 at 6:00 PM. RDO The facility has posted notifications throughout the building on who should be contacted if the facility abuse coordinator is not available or does not respond. Done 11/16/2017 at 9:30 PM. ADMIN The RDO and RNC will review the grievance book bi-monthly when they are in the facility to ensure that all allegations of abuse and/or neglect have been handled appropriately. RDO, RNC Ambassadors will conduct random interviews during their daily rounding regarding staff treatment of [REDACTED]. Rounding sheets will be turned into the Administrator daily for review. ADMIN, RDO The manager on duty for the weekend will conduct random interviews with residents regarding staff treatment of [REDACTED]. Any manager that receives a negative comment from a resident will call the abuse coordinator within 30 minutes of being made aware. Training will be completed by 11/17/2017 at 11:45 AM. Department Managers Any negative comments noted on the daily rounding sheets by the Administrator will require a phone call to the RDO and RNC for discussion within 1 hour of being made aware. In-service done 11/16/2017 at 6:00 PM. RDO Daily Ambassador rounding sheets will be kept in a notebook in the Administrator's office starting 11/17/2017. Daily Ambassador rounding sheets will be reviewed bi-monthly by the RDO and RNC during their routine visits. ADMIN, RDO, RNC RNC will educate all Ambassadors on how to conduct a safe survey with a resident who has a negative comment to identify potential abuse and/or neglect allegations. In-service was completed at noon on 11/17/2017. RNC *Steps taken to achieve the Goal The survey team monitored the Plan of Removal from 11/17/2017 to 11/18/17 as follows: 1. Observed in-Services as listed in the Plan of Correction. 2. Interviewed staff members regarding their knowledge of in-service subject matter as well as general knowledge of Abuse/Neglect policies and procedures. 3. Interviewed Residents regarding their general feeling of safety and if they had any concerns regarding any staff members. 4. Reviewed in-service sign in logs as well as written material distributed during the in-services. On 11/18/17 at 3:10 PM the Facility Administrator, was informed the IJ was removed. However, the facility remained out of compliance at actual harm with a scope as pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. Resident #16 was listed as a curernt resident according to the facility roster.

Based on observation, record review and interview the facility failed to ensure an allegation of verbal abuse was reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one of 21 residents reviewed for abuse (Resident #16). The facility staff, CNA J and CMA K failed to immediately report witnessed verbal abuse towards Resident #16 from Housekeeper A when Housekeeper A confronted and yelled at Resident #6 after the resident filed grievances about Housekeeper A. The facility Administrator,who was the Abuse Coordinator, failed to investigate and suspend Housekeeper A after Resident #16 reported an allegation of verbal abuse from Housekeeper A. Housekeeper A was allowed to continue regular work duties. The Admistrator failed to report that allegation of verbal abuse involving Resident #16 to a State Agency. Housekeeper A started intimidating Resident #16 after her grievance was filed on 11/15/2017 and the Administrator was aware. Resident #16 had episodes of crying and became fearful when leaving her room. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 11/17/17. While the IJ was removed on 11/18/17, the facility remained out of compliance of actual harm with a scope identified as pattern. These failures resulted in psychological harm for Resident #16. Findings include: Review of Resident #16's Face Sheet reflected a [AGE] year old female, reflected the following Diagnoses: [REDACTED]. Review of Resident #16's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 15 indicating the resident was cognitively intact. Review of Resident #16's Care Plan dated 06/14/2017, reflected she required assistance for Activities of Daily Living (ADLs) with one person assist. Review of a grievance report written by the Administrator dated 11/15/2017 for Resident #16 reflected an incident of Housekeeper A being disrespectful, mean tone towards the resident. Housekeeper A was moved off the hallway and assigned to another hallway. Housekeeper A was verbally counseled on how to and how not to engage with residents. The report reflected no further action. Review of a statement written by Housekeeper A dated 11/17/17 reflected I got into a confrontation with (Resident #16). In the confrontation I asked (Resident #16) did she want another grievance form to write another one on me. I told her (the resident) I was obligated (sic) to talk to whoever I wanted. In an interview on 11/16/2017 at 11:50 AM Resident #16 stated Yesterday I was sitting in the chair. (Housekeeper A) came in yelling, she knew I filed grievances, and said to me You going to write some more? The resident stated she went into the hallway crying and looking to speak to the Administrator. The resident stated in the past she would ask the Housekeeper A for more bags and paper towels and the Housekeeper A would have an attitude or just stare at her. Resident #16 further stated that, after the first confrontation, the Housekeeper A came back the next day and stood in her doorway talking about her to CNA J and CMA K. She also stated she felt scared and didn't want the Housekeeper A near her. Resident #16 stated she could hear the Housekeeper A outside of her room laughing at her. Resident #16 stated she wrote grievances against the Housekeeper A about cleaning but she didn't expect the Housekeeper A to confront her about the grievances or make her feel bad. Resident #16 stated she told the Administrator but felt the Administrator thought she was a liar. Resident #16 stated she was crying as she told the Administrator about the verbal abuse. The resident further stated the Administrator told her to go back to her room. In an interview on 11/16/2017 at 2:15 PM, CNA J stated that on 11/17/2017 she spoke with Resident #16 who had told her that Housekeeper A had come up to her and stated If you want to file grievances then file them adding many mean comments, and yelling. The CNA further stated the Resident told the Administrator of her allegation the Administrator sided with the Housekeeper A. CNA J further stated, earlier that day, she witnessed Housekeeper A , had walked over to 100 hall when she wasn't working the 100 hall and stated to them I'm no longer on this hall and it's because of your girl. CNA J stated the Housekeeper A said all this in front of Resident #16's door. Resident #16 later then stated to CNA J that the Housekeeper A had looked at her while she talked in front of her door and the Housekeeper A shouldn't be around her or on the hall. CNA J stated she stayed with Resident #16 until Housekeeper A left the 100 hall because the Resident appeared fearful around Housekeeper A. CNA J continued to state the Housekeeper A would skip cleaning rooms. The Housekeeper A also didn't clean another resident's toilet or room when she had bowel movements. The DON was notified of the Housekeeper A not cleaning properly. CNA J further stated the Housekeeper A had a tone like she was better than the residents. CNA J further stated she did not report the conversation to the Administration because she thought the Administrator was already aware of the issue. In an interview on 11/16/2017 at 2:15 PM, CMA K stated Resident #16 told her about the incident and had been crying. CMA K further stated she told the resident to talk to the Administrator. CMA K stated when more than one resident came to her with issues with the Housekeeper A she told them to tell the abuse coordinator (Administrator). CMA K also stated she told the residents Don't tell me. I am just the med aide. Tell the Administrator about the allegations. CMA K then stated she had told Housekeeper A about her language. She stated the Housekeeper A had even been smart to the Housekeeper A manager. CMA K stated she witnessed Housekeeper A being hostile because she was being moved to another hall after Resident #16 wrote the grievance. CMA K further stated she did not report what she had learned to the Administrator because she was under the impression he was already aware of the issue. In an interview on 11/16/2017 at 2:15 PM, Housekeeper A stated I told (Resident #16) I know you filed a grievance but did you tell the good in your grievance? She then stated she told Resident #16 I'm obligated (sic) to talk to who I want to talk to. The Housekeeper A stated she went to hall 100 the previous day where Resident #16 room was located. The Housekeeper asked Resident #16 why she filed a second grievance and Resident #16 said it's because I was talking to a nurse in front of her door. The Housekeeper A stated she has been mad at her for not cleaning the floor. In an interview on 11/17/2017 at 8:40 AM, the DON stated Resident #16 did not cry a lot and is not typically crying. She stated the only part of the incident she was aware of is on 11/15/2017 when she seen the resident upset running over to the phone. She also stated she then told the Administrator to look at the upset resident on the phone and the Administrator nodded to her that he knew about her being upset. She stated she saw Resident #16 visibly upset and on the phone at the nurses station but never got to interview the resident about why she was upset. The DON stated confronting residents about grievances is inappropriate. The DON also stated she understood how this is a situation to report to the state. In an interview on 11/17/2017 at 8:56 AM, the Administrator stated he never called Resident #16 a liar and he never told her to go back to her room. He was unaware of the Housekeeper A saying things to the resident in an aggressive manner because he had not yet spoken to the resident. He was aware Resident #16 was distraught, and he stated he didn't interview her (Resident #16). He stated he was aware the Housekeeper A confronted the resident about the grievance and could have possibly talked to her in a disrespectful manner. The Administrator stated he did not immediately intervene because Resident was distraut. The Administrator stated my mistake was not reporting the allegation of verbal abuse when it happened. He then stated we will discuss all allegations from this point forward to make sure that things that are reportable are reported. The Administrator further stated that he was familiar with the facility's abuse policy. In an interview on 11/17/2017 at 8:56 AM, the SW stated she would report anything that the resident told her about being hurt. She further stated I would report it to the Administrator because he is the abuse coordinator. The SW stated she (Housekeeper A) shouldn't have spoken to the resident about the grievance and the Housekeeper A shouldn't have gone back to the resident's area. She further stated I would report if a resident or family reported to me or staff they were spoken ugly to. In an interview on 11/17/2017 at 9:43 AM, Resident #16's son stated when he came to the facility he saw Resident #16 was shaking. He stated he did not know how the Housekeeper A knew about the grievance that led her to confront Resident #16. He stated the Administrator automatically believed the Housekeeper A over Resident #16. He further stated that it was completely out of character for Resident #16 to cry for two days. In the past, before the incident occurred, he stated she was always wanting to meet new people, smiling, and laughing. However, after the incident, Resident #16 was scared and would only go to the activity room and back to her room, he didn't understand why the cleaning staff confronted Resident #16. He continued to state Resident #16 was in her room and didn't want to come out of her room because, on the previous day, the Housekeeper A had been in front of her room laughing at her, Resident #16 didn't want to go to the Thanksgiving event. The complainant stated the facility was trying to make it seem like it didn't happen but it did and could be worse next time. He further stated Resident #16 feared reprisal from the facility staff. In an interview on 11/17/2017 at 9:59 AM, The Housekeeper A manager stated the Housekeeper A had stated in the past I'll clean when I feel like it The housekeeping supervisor wasn't aware of the incidents that occurred with Resident #16. She was only aware of Resident #16's grievance of the Housekeeper A not cleaning her room. Review of the policy Abuse-Reportable Events dated 07/2017, reflected a policy: It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/ event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. Definitions Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm, pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct. Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly though words or physical action which causes or could cause mental/ psychological, or physical abuse, including corporal punishment, involuntary seclusion, or any other actions within this definition. Mental/psychological abuse: Mistreatment within the definition of abuse means to inappropriately treat or exploit a resident, not resulting in physical harm, including, but not limited to, humiliation, harassment, threats of punishment, deprivation, or intimidation. Verbal abuse: The use of oral, written, or gestured language that includes disparaging derogatory terms to a resident or within the resident's hearing distance, regardless of the resident's age, ability to comprehend, or disability. Procedure 1. Screening 2. Training 3. Prevention 4. Identification 5. Investigation When an employee becomes aware of an allegation or suspicion of abuse the employee should immediately the allegation or suspicion to the charge nurse on the unit on which the resident resides immediately. The abuse coordinator will: Review all aspects of the investigation as soon as possible. Ensure that all reports are complete and appropriate authorities have been notified including the notification of the local law enforcement related to any crimes against a resident. Complete the investigation and direct any disciplinary action required. Complete the State Provider Investigation Report (5 day report). Review corrective action(s). Inform the resident or his/her representative of the findings of the investigation and corrective action taken 6. Protection All residents will be immediately protected from harm. All allegations involving staff will necessitate suspension without pay, pending investigation. If the allegations is substantiated, the employee will be terminated immediately without pay retroactive to the date of removal from employment. 7. Reporting All alleged allegations of abuse will be reported to the appropriate state agency and to all other agencies as required by regulation. After investigation, administration will analyze the occurrence to determine what changes, if any, are needed for the policies and procedures to prevent further occurrences. In an interview on 11/17/2017 at 10:30 AM the Survey Team Leader informed the Administrator, DON, Regional Administrative Director and Regional Nurse that an Immediate Jeopardy was identified due to the above failures. In an interview on 11/17/2017 at 11:58 AM, Resident #16 stated she got her nails done and went back to her room, she didn't normally stay in her room but since the incident she didn't feel safe in the facility. In an interview on 11/17/2017 at 2:13 PM, the SW stated she should talk to the resident and find out what's going on and report to the abuse coordinator. The SW was unaware of the allegations. The SW stated she knew that after abuse were alleged she needed to talk with the complaining resident to see if she was comfortable and what she could do to help. In an interview on 11/17/2017 at 4:02 PM, the SW stated she had not yet assessed the resident after the abuse allegation. She was unaware about the allegations until I informed her. She stated she only spoke to the resident the day before about her old roommate. The SW was in a care plan meeting and couldn't assess Resident #16 earlier because she had been watching a movie. In an interview on 11/17/2017 at 4:15 PM The Regional Operations Director stated When the Administrator saw the resident crying and upset that should've been his cue to investigate. In an interview on 11/17/2017 at 4:30 PM, the SW stated to the Survey Team Coordinator that she had just assessed the resident at that time and Resident #16 was a little scared and distressed. The facility's third draft of the Plan of Removal was accepted on 11/17/2017 at 5:15 PM in the presence of the facility's Administrator. The plan included: Facility: Lampstand Nursing & Rehab Plan of Removal # 3 Date:11/17/2017 Problem: Failure to recognize potentially abusive situations, conduct a thorough investigation and reporting allegations of abuse and/or neglect. Goal: The facility will recognize potentially abusive situations and thoroughly investigate and report all allegations of abuse and/or neglect. Goal Date: 11/18/2017 *Approaches: Responsible Person(s) **Monitoring: Facility Medical Director was notified that an Immediate Jeopardy was called and was notified on 11/17/2017 at noon. Regional Nurse Consultant 11/16/ 2017 at 3:45 PM the RDO was made aware that the Administrator failed in identify the allegation of abuse from 11/15/2017. The employee in question was immediately suspended on 11/16/2017 at 4:00 PM. Resident # 16 mental state was assessed by Social Worker on 11/17/2017 at 4:33 PM and the resident states that she is a little scared, and a little afraid. Resident # 16 will continue to be monitored every day until she returns to her emotional baseline. Monitoring will be conducted by the social worker or licensed nurse. Resident #16 will be referred to psychological services prior to 11/22/2017 Regional Director of Operations Social Worker / Licensed Nurse Safe surveys were started at 5:00 PM on 11/16/2017 for alert residents and Residents on the hallway 1 and 2 (where the alleged perpetrator worked) had safe surveys conducted and will be completed by 11/17/17 by 5:00 PM. No further issues identified. Ambassadors 80% of facility staff will be educated on reporting any allegations of abuse or neglect to the facility abuse coordinator by 11/17/2017 at 2:fpm. 100% staff will be educated on reporting any allegations of abuse or neglect to the facility abuse coordinator by 11/18/2017 at 9:00 AM. Regional Director of Operations, Regional Nurse Consultant, Administrator RDO & RNC 80% of facility staff will be educated on who to call if they call the facility abuse coordinator and that person does not answer or if they do not receive a call back within 30 minutes. Completed by 11/17/2017 at 2:00 PM. 100% of staff will be educated on who to call if they call the facility abuse coordinator and that person does not answer or if they do not receive a call back within 30 minutes by 11/18/2017 at 9:00 AM. RDO. RNC RDO & RNC Facility Administrator received 1 on 1 education on identifying potentially abusive situation, thoroughly investigating and the guidelines for reporting potential abuse and/or neglect allegations. Will be completed by 11/17/2017 completed at 4:30 PM. Backup abuse coordinators are the RDO and RNC. RDO 80% of facility staff will be educated on who the backup abuse coordinator is if the facility abuse coordinator is not available by 11/17/2017 at 2:00 PM. 100% of staff will be educated on who the backup abuse coordinator is if the facility abuse coordinator is not available by 11/18/2017 at 9:00 AM. The backup abuse coordinators will be the RDO and the, RN RNC. RDO, RNC, ADM The facility Administrator has been educated that he must call the RDO and the RNC within 1 hour for any allegations of abuse and/or neglect. 1 on 1 education was done on 11/16/2017 at 6:00 PM. RDO The facility has posted notifications throughout the building on who should be contacted if the facility abuse coordinator is not available or does not respond. Done 11/16/2017 at 9:30 PM. ADMIN The RDO and RNC will review the grievance book bi-monthly when they are in the facility to ensure that all allegations of abuse and/or neglect have been handled appropriately. RDO, RNC Ambassadors will conduct random interviews during their daily rounding regarding staff treatment of [REDACTED]. Rounding sheets will be turned into the Administrator daily for review. ADMIN, RDO The manager on duty for the weekend will conduct random interviews with residents regarding staff treatment of [REDACTED]. Any manager that receives a negative comment from a resident will call the abuse coordinator within 30 minutes of being made aware. Training will be completed by 11/17/2017 at 11:45 AM. Department Managers Any negative comments noted on the daily rounding sheets by the Administrator will require a phone call to the RDO and RNC for discussion within 1 hour of being made aware. In-service done 11/16/2017 at 6:00 PM. RDO Daily Ambassador rounding sheets will be kept in a notebook in the Administrator's office starting 11/17/2017. Daily Ambassador rounding sheets will be reviewed bi-monthly by the RDO and RNC during their routine visits. ADMIN, RDO, RNC RNC will educate all Ambassadors on how to conduct a safe survey with a resident who has a negative comment to identify potential abuse and/or neglect allegations. In-service was completed at noon on 11/17/2017. RNC *Steps taken to achieve the Goal The survey team monitored the Plan of Removal from 11/17/2017 to 11/18/17 as follows: 1. Observed in-Services as listed in the Plan of Correction. 2. Interviewed staff members regarding their knowledge of in-service subject matter as well as general knowledge of Abuse/Neglect policies and procedures. 3. Interviewed Residents regarding their general feeling of safety and if they had any concerns regarding any staff members. 4. Reviewed in-service sign in logs as well as written material distributed during the in-services. On 11/18/17 at 3:10 PM the Facility Administrator, was informed the IJ was removed. However, the facility remained out of compliance of actual harm at a scope as pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. Resident #16 was listed as a curernt resident according to the facility roster.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for one (1) of four (4) residents (Resident #6) reviewed for a significant change in condition when: 1) LVN E failed to notify the family on 10/23/2015 as requested by the Nurse Practitioner (NP) to determine if the family would like a [DEVICE] (Gastrostomy tube) inserted after Resident # 6 had refused breakfast and lunch. 2) Facility staff failed to accurately assess Resident # 6's continued decline when she became more lethargic, continued to refuse meals and drink little to no fluids on 10/24-25/2015. Facility staff did not notify the physician of Resident # 6's decline until Resident # 6's daughter intervened on 10/25/2015. This decline resulted in Resident # 6 being hosptalized on [DATE] with the [DIAGNOSES REDACTED]. This deficient practice affected one (1) resident (Resident #6) and placed the ¿¿11current residents with weight loss at risk of further weight loss or dehydration. Findings include: Review of Resident # 6's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident # 6's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected Resident # 6 had poor short term and long term memory, severely impaired vision, rarely never understands what is being said to her, rarely/never is verbally understood by others, required total assistance of one (1) person for assistance with all ADL's (Activities of Daily Living) with the exception of eating, which required limited assistance of one (1) person and had not experienced a weight loss. Review of Resident # 6's Plan of Care, last updated on 09/20/2015 reflected a problem with Resident # 6 being on a pureed diet with nectar thickened liquids. Interventions included Serve diet as ordered and offer a substitute if less than 75% is eaten, monitor intake, Offer snacks within diet, Weigh every month an as needed-report 5% weight loss or gain to MD and Responsible Party, and super cereal with breakfast, house shake with lunch and supper. Review of the hospital emergency record dated 10/26/2015, reflected Resident # 6 arrived at the emergency room at 7:05 AM with the following Vital Signs: Blood Pressure (BP): 131/81Temperature (T): 101.0, Pulse (P): 119, Respirations (R): 29. Resident # 6 was documented as being lethargic, and responsive only to painful stimuli. Further review of the emergency room record reflected Resident # 6 had a Sodium level of 163 (normal is 135-145 mg/ml). Resident # 6 was admitted to the hospital on [DATE] with the following Diagnosis: [REDACTED]. Observations made on 10/27/2015 at 8:30 AM at the hospital with the Hospital LVN present, reflected Resident # 6 was laying in bed, with oxygen in place at six (6) liters per mask and an indwelling catheter in place with 200 cubic centimeter (cc) dark clear urine in the catheter bag. Resident # 6 was nonresponsive when the surveyor attempted to speak to her. In an interview on 10/27/2015 at 835 AM the Hospital LVN stated Resident # 6 had been unresponsive since she had arrived at the facility on 10/26/2015. In an interview on 10/28/2015 at 9:15 AM CNA M stated she cared for Resident # 6 routinely on the day shift. CNA M stated on 10/22/2015 Resident # 6 only ate 25 % of breakfast and none of her lunch. CNA M stated she notified LVN E, who told her to put Resident # 6 back to bed. CNA M stated on 10/22/2015 Resident # 6 only voided one (1) time at the beginning of her shift. CNA M stated on 10/23/2015 Resident # 6 would not open her eyes or respond when CNA M called her name. CNA M stated Resident # 6 did not urinate or have a bowel movement on the day shift. CNA M stated she again told LVN E and was told to leave Resident # 6 in bed. CNA M stated when she came to work on 10/25/2015 she found Resident # 6 was still unresponsive and was unable to eat or drink anything. She stated when she told LVN F Resident # 6 looked worse LVN F told her she was waiting on Resident # 6's physician to call back. In an interview on 10/28/2015 at 9:00 AM, CNA N stated she took care of Resident # 6 10/24/2015-10/25/2015. She stated when she attempted to feed Resident # 6 she would pocket the food and the thickened liquids would just run out of her mouth. She stated on Resident # 6 did not urinate or have a bowel movement on 10/24/2015 or 10/25/2015 during the day shift. CNA N stated when she told LVN F on 10/24/2015 she and the Weekend Supervisor went to see Resident # 6. CNA N stated LVN N told her to not attempt to feed Resident # 6. CNA N stated Resident # 6's daughter came to visit several times a week, but did not see her the weekend on 10/24/2015-10/25/2015. In an interview on 10/28/2015 at 2:00 PM CNA P stated she cared for Resident # 6 the 2-10 shift on 10/22-25/2015. After reviewing the meal intake documentation sheet CNA P confirmed Resident # 6 at 25% of her supper meal on 10/22/2015, and did not eat anything for supper on 10/23-25/2015. CNA P stated Resident # 6 only took sips of fluid on 10/23/2015 and was unable to get Resident # 6 to consume any fluids on 10/24-10/25/2015. CNA P stated Resident # 6 did not void as much on 10/24-25/2015. She stated she normally changed her brief three (3) times a shift, but on 10/24-25/2015 she only changed the brief one (1) to two (2) times and Resident # 6 had voided approximately half the amount she normally would. CNA P stated she informed LVN F of the changes with Resident # 6. In an interview on 10/27/2015 at 5:00 PM CNA O stated cared for Resident # 6 on the 10PM-6AM shift on 10/24-25/2015. CNA O stated Resident # 6 did not wake up while she was performing incontinent care both nights. CNA O stated on the morning of 10/26/2015, a little before 6:00 AM she found Resident # 6 breathing rapidly and making a gurgling sound. CNA O stated she immediately went and notified LVN G. Review of the facility Nurses Notes reflected the following: 10/23/2015 at 12:00 PM: Resident continues to refuse medications and meals. Attempted four (4) times to offer water, 0% consumed. NP (Nurse Practitioner) notified. Request speak c/ (with) family about alternative method. 10/23/2015 at 8:00 PM: Spoon fed per staff. Poor appetite. Approx. (approximately) awake. 10/24/2015 at 1:00 AM: Resting quietly in bed. No s/x (signs/symptoms) distress noted. Cont. (Continue) to monitor. 10/24/2015 at 9:00 AM: Pt. drowsy. Refused meal, fed attempting spoon feeding per staff. V/S (vital signs) 107/63: BP (blood pressure), P: 68; T: 97.6, O2 Sat (Oxygen Saturation) 98. Several attempts to awaken, briefs noted to be dry by staff during brief changing. Will continue to monitor. 10/25/2015 at 3:00 AM: Res (Resident) lying in bed. BP 109/70 P 65 T 97.9 R 18. No signs/symptoms of distress at this time. Continue to monitor. 10/25/2015 at 5:00 AM: CNA reports resident had wet brief x (times) 1 this shift (10 p-6 a). Cont.to monitor resident. 10/25/2015 at 2:00 PM: Resident laying in bed. VS: BP 103/68, P: 61 R: 20 T: 98.4. Resident lethargic, decreased appetite noted. No fluid intake during breakfast, 50 ml during lunch. 10/25/2015 at 7:00 PM: RP (Responsible Party) #2 voiced concern c/ resident not eating or drinking; stated she wants everything to be done to get food/nutrition in resident; stated resident had a [DEVICE] previously but she pulled it out; care conf. (conference) call will be initiated on 10/26/15 per RP request . 10/25/2015 at 8:00 PM: MD (Medical Doctor) on call service called @ (at) 6:15 PM. No call back. NP called. NP suggested to wait until AM tomorrow. Family notified of NP's suggestion Family requested to be called first thing in AM for conference. Put in 24 hour report. 10/25/2015 at 8:00 PM: Attempted to assist pt. to drink thickened ready care drink (supplement). Resident did not swallow, kept in mouth. Will continue to encourage liquids. 10/26/2015 at 12:00 AM; Res. Lying in bed c/ eyes closed. BP 110/63 P 62 R 20 T 97.8. Resp. even/unlabored. Skin warm/dry to touch. CNA reports wet brief x 1. Cont. to monitor resident. 10/26/2015 at 6:00 AM: Called to res. room by CNA Res. Breathing is rapid/labored. PRN Neb (Nebulizer) tx (treatment) given. O2 (3 L/NC) Sats @ 90% BP 117/60 P 112 R 24. NP contacted, gave N/O (Nurses Order) to send Pt. to ER (emergency room ). Ambulance contacted .Skin is warm/dry. Skin recoil is 4 seconds. Oval mucosa noted to be dry pink. 10/26/2015 at 6:15 AM BP 107/63 P 109 R 20 SPO2 91% on 3 L/min. O2 via NC. Ambulance @ facility taking resident to Hospital ER. RP contacted, notified of transfer to Hospital ER. Review of the October ADL (Activities of Daily Living) reflected Resident # 6's meal intake was: 10/22/2015: Breakfast-25%, Lunch-Refused, Supper-25% 10/23/2015: Breakfast-Refused, Lunch-Refused, Supper-25% 10/24/2015: Breakfast-Refused, Lunch-Refused, Supper-Refused 10/25/2015: Breakfast-Refused, Lunch-Refused, Supper-Refused In an interview on 10/28/2015 at 9:30 AM, LVN E stated she had notified the Nurse Practitioner (NP) on 10/23/2015 at 12:00 PM that Resident # 6 was not as active as she usually was and had only eaten 25 % of her supper on 10/22/2015 and refused her breakfast and lunch on 10/23/2015. LVN E stated the NP asked her if Resident # 6 had any laboratory tests conducted recently. She said she told the NP yes, but did not clarify the laboratory work was completed on 10/05/2015, 18 days before she had concerns regarding Resident # 6's decline. LVN E stated she understood that the NP or Resident # 6's physician was going to speak with the family regarding the placement of a [DEVICE] (but never verbally confirmed this). LVN E stated the NP stated the [DEVICE] could not be inserted before Monday. LVN E stated she did not speak with either Responsible Party regarding Resident # 6 decline or if the family wanted Resident # 6 to have a [DEVICE] placed. In an interview on 10/28/2015 at 9:45 AM, LVN F (works weekends 6 AM-10 PM) stated Resident # 6 did not eat on 10/24/2015 and 10/25/2015 had no cough/congestion, and was very lethargic. She stated she was not aware Resident # 6 had a decrease in her urine output over the weekend. LVN F stated she was not aware the family was unaware of Resident # 6's decline until Resident # 6's daughter came to the facility the late afternoon of 10/25/2015. LVN F stated she call the physician on-call service and left a message on 10/25/2015 at 6:15 PM. LVN F stated Resident # 6's daughter called the facility approximately 45 minutes later and she told her the physician had not called back, but she would call the NP. LVN F stated when she called the NP she told her Resident # 6 was lethargic and not eating or drinking much the past two (2) days. LVN F stated she had not looked back at the meal intake documentation to see how many days Resident # 6 had not been eating/drinking. LVN F stated the NP said she thought Resident # 6 could wait until the next morning to go to the hospital for a [DEVICE], but if the family was concerned she could send Resident # 6 that evening to the hospital emergency room for an evaluation. LVN F stated when she called Resident # 6's daughter back she told her the NP had said Resident # 6 could wait until the next day to go to the emergency room and that LVN F stated she would try to get Resident # 6 to drink some fluids again. LVN F stated Resident # 6 had asked her to please take care of my mother and to call her first thing in the morning for a care conference regarding her mother's care. In an interview on 10/28/2015 at 10:55 AM the NP stated she was notified by LVN E on 10/23/2015 that Resident # 6 had not eaten well or refused to eat on 10/22/2015 for supper and breakfast and lunch on 10/23/2015. The NP stated she had told LVN E to check with the family and see if they would like Resident # 6 to have a [DEVICE]. The NP stated she was not aware Resident # 6 was refusing fluids on 10/23/2015. The NP stated she would have expected the licensed nurses to have called her back as Resident # 6 continued to decline on 10/24-10/25/2015. The NP stated she was not contacted by the facility until the evening of 10/25/2015 when LVN F stated Resident # 6 was still not eating. The NP stated she was not aware Resident # 6 was not as responsive, drinking sips to no fluids during the weekend, and had periods of no or decreased urine output. The NP stated if she had been aware of these symptoms she would have sent Resident # 6 to the hospital emergency room earlier. She also stated when LVN F had called her on 10/25/2015 she had told LVN F if the family was concerned and wanted Resident # 6 to go to the emergency room , to write an order for [REDACTED]. In an interview on 10/28/2015 at 10:10 AM, the Corporate DON stated she was working as the facility RN on Sunday, 10/25/2015, when she spoke with Resident # 6's daughter. She stated Resident # 6's daughter was upset she not been called that her mother had not been eating and had been taking fluids poorly for the past three (3) days. The Corporate DON stated she told Resident # 6's daughter that LVN E had notified Resident # 6's brother on 10/23/2015 of her mother's decline. When the surveyor asked the Corporate DON to show the surveyor the documentation where Resident # 6's son had been notified of Resident # 6's decline, she pointed to an entry made on 10/01/2015. The Corporate RN stated she must have read the date wrong when she was talking to Resident # 6's daughter. The Corporate RN stated she assisted Resident # 6's daughter in completing a grievance form regarding her concerns regarding not being notified of her mother's decline and then placed the form under the Administrator's door. The Corporate Nurse stated she learned the next day (10/26/2015) at the morning staff meeting that Resident # 6 had been admitted to the hospital. The Corporate DON stated she had not assessed Resident # 6 after she had learned of her decline from Resident # 6's daughter. The Corporate DON stated her priority that afternoon was to calm down Resident # 6's daughter. In an interview on 10/28/2015 at 5:00 PM, Resident # 6's daughter stated she was not notified of her mother's decline. Resident # 6's daughter stated when she arrived at the facility on 10/25/2015 she was very concerned about her mother's condition. She stated she had told LVN F that she thought her mother should be taken to the hospital. Resident # 6's daughter stated she received a telephone call from LVN later in the evening on 10/25/2015 and was told the NP did not see a need for Resident # 6 to be sent to the hospital until 10/26/2015 when a [DEVICE] could be inserted. In an interview on 10/28/2015 LVN G stated on 10/26/2015 at approximately 6:00 AM she was informed by CNA O that Resident # 6 was breathing rapidly. She stated she gave Resident # 6 a prn nebulizer treatment which appeared to help. LVN G stated she called the NP and received an order to transfer Resident # 6 to the emergency room for an evaluation. In an interview on 10/28/2015 at 11:10 AM the DON stated she was unaware of the change of condition Resident # 6 had experienced from 10/22/2015 to 10/26/2015 until she went to the morning clinical meeting on 10/26/2015. She stated she expected the charge nurses to communicate to her if resident's were experiencing a decline. She also stated she was unaware Resident # 6's family was upset until she read an e-mail the evening of 10/25/2015 from the Corporate DON. The DON stated she would have expected LVN E to have spoken with Resident # 6's Responsible Party regarding the possibility of Resident # 6 having a [DEVICE] placed. The DON stated if LVN E did not feel comfortable talking to the family she would have spoken to the family. The DON stated she would have expected the Corporate DON would have assessed Resident # 6 when she learned from Resident # 6's daughter that Resident # 6 had not been eating or drinking for the past three (3) days. She also stated she felt the charge nurses should have reviewed meal and fluid intake and notified the NP after a complete assessment had been completed. Review of the facility policy, Change of Condition-Observing, Reporting and Recording, with a revision date of 03/2012 reflected the following: It is the policy of this home to inform the resident's physician and if indicated the residents responsible party of the following: . 2. A significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications .4. A need to alter treatment significantly . The facility provided a list of eleven residents with weight loss.

Based on observation, interview and record review the facility failed to immediately consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications) or a need to alter treatment significantly for one (1) of four (4) residents (Resident #6) reviewed for a significant change in condition when: 1) LVN E failed to ensure Resident # 6's family was contacted on 10/23/2015 regarding the possible placement of a gastrostomy tube ([DEVICE]) as requested by the Nurse Practitioner (NP) due to resident's recent refusal to eat. 2) The facility nursing staff failed to notify Resident # 6's Physician/NP when Resident # 6 continued to refuse to eat and take minimal to no fluids, and became more lethargic on 10/24/2015 and 10/25/2015 until Resident # 6's daughter requested Resident # 6's physician be notified the afternoon of 10/25/2015. 3) Resident # 6 was sent to the hospital by ambulance on 10/26/2015 at approximately 6:30AM when Resident # 6 was assessed to have rapid and labored breathing. Resident # 6 was admitted to the hospital with [REDACTED]. This deficient practice affected one (1) resident (Resident #6) and placed the ¿11 current residents with weight loss at risk of further weight loss, and dehydration. Findings include: Review of Resident # 6's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident # 6's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected Resident # 6 had poor short term and long term memory, severely impaired vision, rarely never understands what is being said to her, rarely/never is verbally understood by others, required total assistance of one (1) person for assistance with all ADL's (Activities of Daily Living) with the exception of eating, which required limited assistance of one (1) person and had not experienced a weight loss. Review of Resident # 6's Plan of Care, last updated on 09/20/2015 reflected a problem with Resident # 6 being on a pureed diet with nectar thickened liquids. Interventions included Serve diet as ordered and offer a substitute if less than 75% is eaten, monitor intake, Offer snacks within diet, Weigh every month an as needed-report 5% weight loss or gain to MD and Responsible Party, and super cereal with breakfast, house shake with lunch and supper. Review of the hospital emergency record dated 10/26/2015, reflected Resident # 6 arrived at the emergency room at 7:05 AM with the following Vital Signs: Blood Pressure (BP): 131/81Temperature (T): 101.0, Pulse (P): 119, Respirations (R): 29. Resident # 6 was documented as being lethargic, and responsive only to painful stimuli. Further review of the emergency room record reflected Resident # 6 had a Sodium level of 163 (normal is 135-145 mg/ml). Resident # 6 was admitted to the hospital on [DATE] with the following Diagnosis: [REDACTED]. Observations made on 10/27/2015 at 8:30 AM at the hospital with the Hospital LVN present, reflected Resident # 6 was laying in bed, with oxygen in place at six (6) liters per mask and an indwelling catheter in place with 200 cubic centimeter (cc) dark clear urine in the catheter bag. Resident # 6 was nonresponsive when the surveyor attempted to speak to her. In an interview on 10/27/2015 at 835 AM the Hospital LVN stated Resident # 6 had been unresponsive since she had arrived at the facility on 10/26/2015. In an interview on 10/28/2015 at 9:15 AM CNA M stated she cared for Resident # 6 routinely on the day shift. CNA M stated on 10/22/2015 Resident # 6 only ate 25 % of breakfast and none of her lunch. CNA M stated she notified LVN E, who told her to put Resident # 6 back to bed. CNA M stated on 10/22/2015 Resident # 6 only voided one (1) time at the beginning of her shift. CNA M stated on 10/23/2015 Resident # 6 would not open her eyes or respond when CNA M called her name. CNA M stated Resident # 6 did not urinate or have a bowel movement on the day shift. CNA M stated she again told LVN E and was told to leave Resident # 6 in bed. CNA M stated when she came to work on 10/25/2015 she found Resident # 6 was still unresponsive and was unable to eat or drink anything. She stated when she told LVN F Resident # 6 looked worse LVN F told her she was waiting on Resident # 6's physician to call back. In an interview on 10/28/2015 at 9:00 AM, CNA N stated she took care of Resident # 6 10/24/2015-10/25/2015. She stated when she attempted to feed Resident # 6 she would pocket the food and the thickened liquids would just run out of her mouth. She stated on Resident # 6 did not urinate or have a bowel movement on 10/24/2015 or 10/25/2015 during the day shift. CNA N stated when she told LVN F on 10/24/2015 she and the Weekend Supervisor went to see Resident # 6. CNA N stated LVN N told her to not attempt to feed Resident # 6. CNA N stated Resident # 6's daughter came to visit several times a week, but did not see her the weekend on 10/24/2015-10/25/2015. In an interview on 10/28/2015 at 2:00 PM CNA P stated she cared for Resident # 6 the 2-10 shift on 10/22-25/2015. After reviewing the meal intake documentation sheet CNA P confirmed Resident # 6 at 25% of her supper meal on 10/22/2015, and did not eat anything for supper on 10/23-25/2015. CNA P stated Resident # 6 only took sips of fluid on 10/23/2015 and was unable to get Resident # 6 to consume any fluids on 10/24-10/25/2015. CNA P stated Resident # 6 did not void as much on 10/24-25/2015. She stated she normally changed her brief three (3) times a shift, but on 10/24-25/2015 she only changed the brief one (1) to two (2) times and Resident # 6 had voided approximately half the amount she normally would. CNA P stated she informed LVN F of the changes with Resident # 6. In an interview on 10/27/2015 at 5:00 PM CNA O stated cared for Resident # 6 on the 10PM-6AM shift on 10/24-25/2015. CNA O stated Resident # 6 did not wake up while she was performing incontinent care both nights. CNA O stated on the morning of 10/26/2015, a little before 6:00 AM she found Resident # 6 breathing rapidly and making a gurgling sound. CNA O stated she immediately went and notified LVN G. Review of the facility Nurses Notes reflected the following: 10/23/2015 at 12:00 PM: Resident continues to refuse medications and meals. Attempted four (4) times to offer water, 0% consumed. NP (Nurse Practitioner) notified. Request speak c/ (with) family about alternative method. 10/23/2015 at 8:00 PM: Spoon fed per staff. Poor appetite. Approx. (approximately) awake. 10/24/2015 at 1:00 AM: Resting quietly in bed. No s/x (signs/symptoms) distress noted. Cont. (Continue) to monitor. 10/24/2015 at 9:00 AM: Pt. drowsy. Refused meal, fed attempting spoon feeding per staff. V/S (vital signs) 107/63: BP (blood pressure), P: 68; T: 97.6, O2 Sat (Oxygen Saturation) 98. Several attempts to awaken, briefs noted to be dry by staff during brief changing. Will continue to monitor. 10/25/2015 at 3:00 AM: Res (Resident) lying in bed. BP 109/70 P 65 T 97.9 R 18. No signs/symptoms of distress at this time. Continue to monitor. 10/25/2015 at 5:00 AM: CNA reports resident had wet brief x (times) 1 this shift (10 p-6 a). Cont.to monitor resident. 10/25/2015 at 2:00 PM: Resident laying in bed. VS: BP 103/68, P: 61 R: 20 T: 98.4. Resident lethargic, decreased appetite noted. No fluid intake during breakfast, 50 ml during lunch. 10/25/2015 at 7:00 PM: RP (Responsible Party) #2 voiced concern c/ resident not eating or drinking; stated she wants everything to be done to get food/nutrition in resident; stated resident had a [DEVICE] previously but she pulled it out; care conf. (conference) call will be initiated on 10/26/15 per RP request . 10/25/2015 at 8:00 PM: MD (Medical Doctor) on call service called @ (at) 6:15 PM. No call back. NP called. NP suggested to wait until AM tomorrow. Family notified of NP's suggestion Family requested to be called first thing in AM for conference. Put in 24 hour report. 10/25/2015 at 8:00 PM: Attempted to assist pt. to drink thickened ready care drink (supplement). Resident did not swallow, kept in mouth. Will continue to encourage liquids. 10/26/2015 at 12:00 AM; Res. Lying in bed c/ eyes closed. BP 110/63 P 62 R 20 T 97.8. Resp. even/unlabored. Skin warm/dry to touch. CNA reports wet brief x 1. Cont. to monitor resident. 10/26/2015 at 6:00 AM: Called to res. room by CNA Res. Breathing is rapid/labored. PRN Neb (Nebulizer) tx (treatment) given. O2 (3 L/NC) Sats @ 90% BP 117/60 P 112 R 24. NP contacted, gave N/O (Nurses Order) to send Pt. to ER (emergency room ). Ambulance contacted .Skin is warm/dry. Skin recoil is 4 seconds. Oval mucosa noted to be dry pink. 10/26/2015 at 6:15 AM BP 107/63 P 109 R 20 SPO2 91% on 3 L/min. O2 via NC. Ambulance @ facility taking resident to Hospital ER. RP contacted, notified of transfer to Hospital ER. Review of the October ADL (Activities of Daily Living) reflected Resident # 6's meal intake was: 10/22/2015: Breakfast-25%, Lunch-Refused, Supper-25% 10/23/2015: Breakfast-Refused, Lunch-Refused, Supper-25% 10/24/2015: Breakfast-Refused, Lunch-Refused, Supper-Refused 10/25/2015: Breakfast-Refused, Lunch-Refused, Supper-Refused In an interview on 10/28/2015 at 9:30 AM, LVN E stated she had notified the Nurse Practitioner (NP) on 10/23/2015 at 12:00 PM that Resident # 6 was not as active as she usually was and had only eaten 25 % of her supper on 10/22/2015 and refused her breakfast and lunch on 10/23/2015. LVN E stated the NP asked her if Resident # 6 had any laboratory tests conducted recently. She said she told the NP yes, but did not clarify the laboratory work was completed on 10/05/2015, 18 days before she had concerns regarding Resident # 6's decline. LVN E stated she understood that the NP or Resident # 6's physician was going to speak with the family regarding the placement of a [DEVICE] (but never verbally confirmed this). LVN E stated the NP stated the [DEVICE] could not be inserted before Monday. LVN E stated she did not speak with either Responsible Party regarding Resident # 6 decline or if the family wanted Resident # 6 to have a [DEVICE] placed. In an interview on 10/28/2015 at 9:45 AM, LVN F (works weekends 6 AM-10 PM) stated Resident # 6 did not eat on 10/24/2015 and 10/25/2015 had no cough/congestion, and was very lethargic. She stated she was not aware Resident # 6 had a decrease in her urine output over the weekend. LVN F stated she was not aware the family was unaware of Resident # 6's decline until Resident # 6's daughter came to the facility the late afternoon of 10/25/2015. LVN F stated she call the physician on-call service and left a message on 10/25/2015 at 6:15 PM. LVN F stated Resident # 6's daughter called the facility approximately 45 minutes later and she told her the physician had not called back, but she would call the NP. LVN F stated when she called the NP she told her Resident # 6 was lethargic and not eating or drinking much the past two (2) days. LVN F stated she had not looked back at the meal intake documentation to see how many days Resident # 6 had not been eating/drinking. LVN F stated the NP said she thought Resident # 6 could wait until the next morning to go to the hospital for a [DEVICE], but if the family was concerned she could send Resident # 6 that evening to the hospital emergency room for an evaluation. LVN F stated when she called Resident # 6's daughter back she told her the NP had said Resident # 6 could wait until the next day to go to the emergency room and that LVN F stated she would try to get Resident # 6 to drink some fluids again. LVN F stated Resident # 6 had asked her to please take care of my mother and to call her first thing in the morning for a care conference regarding her mother's care. In an interview on 10/28/2015 at 10:55 AM the NP stated she was notified by LVN E on 10/23/2015 that Resident # 6 had not eaten well or refused to eat on 10/22/2015 for supper and breakfast and lunch on 10/23/2015. The NP stated she had told LVN E to check with the family and see if they would like Resident # 6 to have a [DEVICE]. The NP stated she was not aware Resident # 6 was refusing fluids on 10/23/2015. The NP stated she would have expected the licensed nurses to have called her back as Resident # 6 continued to decline on 10/24-10/25/2015. The NP stated she was not contacted by the facility until the evening of 10/25/2015 when LVN F stated Resident # 6 was still not eating. The NP stated she was not aware Resident # 6 was not as responsive, drinking sips to no fluids during the weekend, and had periods of no or decreased urine output. The NP stated if she had been aware of these symptoms she would have sent Resident # 6 to the hospital emergency room earlier. She also stated when LVN F had called her on 10/25/2015 she had told LVN F if the family was concerned and wanted Resident # 6 to go to the emergency room , to write an order for [REDACTED]. In an interview on 10/28/2015 at 10:10 AM, the Corporate DON stated she was working as the facility RN on Sunday, 10/25/2015, when she spoke with Resident # 6's daughter. She stated Resident # 6's daughter was upset she not been called that her mother had not been eating and had been taking fluids poorly for the past three (3) days. The Corporate DON stated she told Resident # 6's daughter that LVN E had notified Resident # 6's brother on 10/23/2015 of her mother's decline. When the surveyor asked the Corporate DON to show the surveyor the documentation where Resident # 6's son had been notified of Resident # 6's decline, she pointed to an entry made on 10/01/2015. The Corporate RN stated she must have read the date wrong when she was talking to Resident # 6's daughter. The Corporate RN stated she assisted Resident # 6's daughter in completing a grievance form regarding her concerns regarding not being notified of her mother's decline and then placed the form under the Administrator's door. The Corporate Nurse stated she learned the next day (10/26/2015) at the morning staff meeting that Resident # 6 had been admitted to the hospital. The Corporate DON stated she had not assessed Resident # 6 after she had learned of her decline from Resident # 6's daughter. The Corporate DON stated her priority that afternoon was to calm down Resident # 6's daughter. In an interview on 10/28/2015 at 5:00 PM, Resident # 6's daughter stated she was not notified of her mother's decline. Resident # 6's daughter stated when she arrived at the facility on 10/25/2015 she was very concerned about her mother's condition. She stated she had told LVN F that she thought her mother should be taken to the hospital. Resident # 6's daughter stated she received a telephone call from LVN later in the evening on 10/25/2015 and was told the NP did not see a need for Resident # 6 to be sent to the hospital until 10/26/2015 when a [DEVICE] could be inserted. In an interview on 10/28/2015 LVN G stated on 10/26/2015 at approximately 6:00 AM she was informed by CNA O that Resident # 6 was breathing rapidly. She stated she gave Resident # 6 a prn nebulizer treatment which appeared to help. LVN G stated she called the NP and received an order to transfer Resident # 6 to the emergency room for an evaluation. In an interview on 10/28/2015 at 11:10 AM the DON stated she was unaware of the change of condition Resident # 6 had experienced from 10/22/2015 to 10/26/2015 until she went to the morning clinical meeting on 10/26/2015. She stated she expected the charge nurses to communicate to her if resident's were experiencing a decline. She also stated she was unaware Resident # 6's family was upset until she read an e-mail the evening of 10/25/2015 from the Corporate DON. The DON stated she would have expected LVN E to have spoken with Resident # 6's Responsible Party regarding the possibility of Resident # 6 having a [DEVICE] placed. The DON stated if LVN E did not feel comfortable talking to the family she would have spoken to the family. The DON stated she would have expected the Corporate DON would have assessed Resident # 6 when she learned from Resident # 6's daughter that Resident # 6 had not been eating or drinking for the past three (3) days. She also stated she felt the charge nurses should have reviewed meal and fluid intake and notified the NP after a complete assessment had been completed. Review of the facility policy, Change of Condition-Observing, Reporting and Recording, with a revision date of 03/2012 reflected the following: It is the policy of this home to inform the resident's physician and if indicated the residents responsible party of the following: . 2. A significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications .4. A need to alter treatment significantly . The facility provided a list of eleven residents with weight loss.

Based on observation, interview, and record review the facility failed to implement policies and procedures to prevent neglect for one (1) of five (5) residents reviewed for bruising (Resident #1). Resident #1 incurred extensive bruising to the left breast, sternum, left clavicle area, left upper extremity and left shoulder of an unknown origin on [DATE]. This injury resulted in Resident #1 being transported to a local hospital on [DATE], where she received additional [DIAGNOSES REDACTED]. This deficient practice caused injury to Resident #1 and could affect 73 residents who needed assistance with transfers at risk for potential discomfort and injury. Findings include: Review of Resident #1's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set ((MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 5 indicating the resident had severe cognitive impairment. The most recent MDS dated [DATE] reflected a BIMS score of 3, also indicative of severe cognitive impairment. The resident ' s functional status for transfers indicated extensive assistance of two people required. The mobility device was a wheelchair. Review of Resident #1's Care plan dated [DATE] reflected the resident had frail skin and bruising and approach indicated two persons needed for transfers. There were no previous care plans provided addressing transferring procedures prior to this date. Review of Resident #1's Activities of Daily Living (ADL) flow sheet utilized by Certified Nursing Assistants (CNA's) dated [DATE] - [DATE] reflected the resident was totally dependent for transfers and required the assistance of two people on all transfers from [DATE] - [DATE]. Observation of Resident #1 on [DATE] at 3:00 pm revealed the resident in her bed. The resident's left side of chest had fading yellowish brown bruising about the size of a small peach. The resident did not grimace or yell out in pain when moved. In an interview on [DATE] at 10:30 am, Resident #1 stared blankly when questions were asked, and said, Yes sluggishly one time when asked if she was getting her hair fixed. She did not respond when asked additional questions about the bruising or if she was in pain. Review of Incident/Accident Report dated [DATE] at 8:30 pm reflected Resident #1 was noted to have dark, purple, and blue bruising to left breast, sternum, left clavicle area, left upper extremity, and left shoulder. Resident ' s physician and daughter were notified prior to transfer to local emergency room . There were no witnesses reported. Review of the facility's Provider Investigation Report for the resident's incident of [DATE] for Resident #1 dated [DATE] reflected assessment was conducted at 6:30 am finding small bruise to left chest area, which LVN C was not concerned about at that time. There was no report of any fall or other incidents which would cause injury. Later at 8:30 pm a second assessment was conducted to find the same hematoma had bled and spread making a large bruised area to chest wall. Physician was notified and Resident #1 was transported to hospital. Through the investigation, no staff member was able to identify a specific incident leading to the bruising. All staff who gave statements during the investigation stated they believed Resident #1 was a two person transfer, and denied doing a transfer otherwise. Review of Nurses Notes dated [DATE] at 8:30 pm signed by Licensed Vocational Nurse (LVN) A reflected Resident #1 had dark purple and blue ecchymosis to left breast, left upper extremity, left clavicle area, sternum area, and left hand. The notation continued by stating the bruised area was tender to touch and Resident #1 complained of pain to left upper extremity with decreased range of motion. Medical Doctor (MD) and Resident #1's daughter were notified. Review of Physician's Telephone Orders dated [DATE] reflected an order to send Resident #1 to a local hospital to be evaluated and treated. Additional information provided on patient information sheet indicated, Solid black, blue, purple bruising to left chest wall, left breast, left upper extremity, clavicle area and sternum area. Resident was transported to the ER by an ambulance on [DATE]. Review of Resident #1's Nurse's Notes dated [DATE] at 12:30 am written by LVN B reflected resident arrived by ambulance and no further orders were indicated. Documentation further stated bruising was tender to touch and Resident #1 complained of pain to left upper extremity and Tylenol ([MEDICATION NAME]) 500 milligrams (mg) was administered to resident. Record Review of Resident #1's Nurse's Notes dated [DATE] at 10:00 am written by LVN C reflected resident was put in bed and given pain medication (unnamed), awaiting facility visit from physician's assistant. In an interview on [DATE] at 10:30 am the facility beautician stated it took two people using a gait belt to transfer Resident #1 because she did not stand at all. The beautician further stated that Resident #1 rarely talked at all and then only answered simple questions with yes/no answers. In an interview on [DATE] at 12:35 pm the daughter of Resident #1 stated she was notified on [DATE] her mother was being transported to the hospital to see if she had a broken rib because the bruising had become so severe. She was informed the facility did not know how the bruising occurred or the causative agent. Once at the hospital, she reported taking pictures on her cell phone of the extensive bruising to her mother's chest and left arm. The daughter stated the bruising was black and purple and extend across her mother ' s whole chest from the right side of the sternum to the left breast and over under the left arm, with what appeared to her to be two imprints of thumbs or knuckles on either side of the sternum, as they appeared a darker color. The daughter stated that she took the pictures and showed them to the police, who were in the hospital on an unrelated incident. The police told her they would report the incident for investigation. The daughter further concluded from the pictures that someone came up behind her mother and pulled her up roughly to reposition her in the wheelchair and kept her from sliding out of the chair. The daughter stated, the person doing this had to have been large, strong, and impatient as the lift is a two person process. She pointed out two places on the pictures on either side of the sternum with noticeable darker pigmentation and more extensive bruising which she concluded were imprints of knuckles. She stated she had scheduled a meeting with the Director of Nursing (DON) and the administrator of the facility on [DATE] to discuss the incident and see what the facility investigation concluded. The administrative staff told her they were still unsure of how the bruising occurred, but after reviewing the pictures, she stated she thought they agreed with her. Resident #1 ' s daughter provided the surveyors with three pictures of her mother, two were taken immediately after the incident and one the next day. Resident #1's daughter stated she was in the facility often, almost daily, because she wanted to know what care her mother was getting, and she worried about her constantly. Review of Resident #1 ' s Emergency Record dated [DATE] reflected the resident was transported via ambulance from the nursing facility and complained of pain to her chest and ribs when palpated. Inspection findings included ecchymosis to left chest and ribs with symptoms localized most severe in the left upper chest and anterior aspect. Cardiac monitoring was indicated for left rib bruising and radiology imaging ordered, which revealed no overt rib fracture. The final [DIAGNOSES REDACTED]. Resident was evaluated and returned to the nursing facility from the local emergency room . In an interview on [DATE] at 4:17 pm the DON indicated the facility never found a clear reason for the bruising on Resident #1's chest and left arm. She added that the physician's assistant (PA) evaluated Resident #1 on [DATE] and reasoned that someone must have come up behind the resident and bear hugged her to move her up in her wheelchair causing the bruising; however, the notes from the PA were unavailable as he died suddenly before notes were turned in and incorporated into the chart. In an interview on [DATE] at 4:20 pm the Administrator stated the PA assessed Resident #1 on [DATE] and believed the bruising may have occurred from repositioning techniques as if someone came from behind and lifted her back up in her chair. At this time the PA ordered a Geri-Chair for repositioning. The Administrator stated she agreed with the conclusion of the PA. Review of a sign in sheet reflected the in-service entitled Handling and Repositioning of Residents was held on [DATE]. There was no additional follow up to the in-service provided with the exception of spot checks according to the DON. Review of the facility's Policy and Procedures titled Transferring a Resident dated ,[DATE] did not reflect repositioning techniques of a totally dependent resident. Review of the facility ' s Policy and Procedures titled Abuse-Reportable Events dated ,[DATE] reflected, It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. Neglect is defined in this policy as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The facility provided CMS Form 672 reflected 73 residents who needed assistance with transfers.

Based on observation, interview, and record review the facility failed to follow their written policies and procedures that prohibit the mistreatment, neglect, and abuse of residents and misappropriation of resident's property for one (1) of five (5) residents (Resident #1) reviewed for abuse and neglect. Resident #1 incurred extensive bruising to the left breast, sternum, left clavicle area, left upper extremity and left shoulder of an unknown origin on [DATE]. This injury resulted in Resident #1 being transported to a local hospital on [DATE], where she received additional [DIAGNOSES REDACTED]. This deficient practice caused injury to Resident #1 and could affect 73 residents who needed assistance with transfers at risk for potential discomfort and injury. Findings include: Review of the facility ' s Policy and Procedures titled Abuse-Reportable Events dated ,[DATE] reflected, It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. Neglect is defined in this policy as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of Resident #1's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set ((MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 5 indicating the resident had severe cognitive impairment. The most recent MDS dated [DATE] reflected a BIMS score of 3, also indicative of severe cognitive impairment. The resident ' s functional status for transfers indicated extensive assistance of two people required. The mobility device was a wheelchair. Review of Resident #1's Care plan dated [DATE] reflected the resident had frail skin and bruising and approach indicated two persons needed for transfers. There were no previous care plans provided addressing transferring procedures prior to this date. Review of Resident #1's Activities of Daily Living (ADL) flow sheet utilized by Certified Nursing Assistants (CNA's) dated [DATE] - [DATE] reflected the resident was totally dependent for transfers and required the assistance of two people on all transfers from [DATE] - [DATE]. Observation of Resident #1 on [DATE] at 3:00 pm revealed the resident in her bed. The resident's left side of chest had fading yellowish brown bruising about the size of a small peach. The resident did not grimace or yell out in pain when moved. In an interview on [DATE] at 10:30 am, Resident #1 stared blankly when questions were asked, and said, Yes sluggishly one time when asked if she was getting her hair fixed. She did not respond when asked additional questions about the bruising or if she was in pain. Review of Incident/Accident Report dated [DATE] at 8:30 pm reflected Resident #1 was noted to have dark, purple, and blue bruising to left breast, sternum, left clavicle area, left upper extremity, and left shoulder. Resident ' s physician and daughter were notified prior to transfer to local emergency room . There were no witnesses reported. Review of the facility's Provider Investigation Report for the resident's incident of [DATE] for Resident #1 dated [DATE] reflected assessment was conducted at 6:30 am finding small bruise to left chest area, which LVN C was not concerned about at that time. There was no report of any fall or other incidents which would cause injury. Later at 8:30 pm a second assessment was conducted to find the same hematoma had bled and spread making a large bruised area to chest wall. Physician was notified and Resident #1 was transported to hospital. Through the investigation, no staff member was able to identify a specific incident leading to the bruising. All staff who gave statements during the investigation stated they believed Resident #1 was a two person transfer, and denied doing a transfer otherwise. Review of Nurses Notes dated [DATE] at 8:30 pm signed by Licensed Vocational Nurse (LVN) A reflected Resident #1 had dark purple and blue ecchymosis to left breast, left upper extremity, left clavicle area, sternum area, and left hand. The notation continued by stating the bruised area was tender to touch and Resident #1 complained of pain to left upper extremity with decreased range of motion. Medical Doctor (MD) and Resident #1's daughter were notified. Review of Physician's Telephone Orders dated [DATE] reflected an order to send Resident #1 to a local hospital to be evaluated and treated. Additional information provided on patient information sheet indicated, Solid black, blue, purple bruising to left chest wall, left breast, left upper extremity, clavicle area and sternum area. Resident was transported to the ER by an ambulance on [DATE]. Review of Resident #1's Nurse's Notes dated [DATE] at 12:30 am written by LVN B reflected resident arrived by ambulance and no further orders were indicated. Documentation further stated bruising was tender to touch and Resident #1 complained of pain to left upper extremity and Tylenol ([MEDICATION NAME]) 500 milligrams (mg) was administered to resident. Record Review of Resident #1's Nurse's Notes dated [DATE] at 10:00 am written by LVN C reflected resident was put in bed and given pain medication (unnamed), awaiting facility visit from physician's assistant. In an interview on [DATE] at 10:30 am the facility beautician stated it took two people using a gait belt to transfer Resident #1 because she did not stand at all. The beautician further stated that Resident #1 rarely talked at all and then only answered simple questions with yes/no answers. In an interview on [DATE] at 12:35 pm the daughter of Resident #1 stated she was notified on [DATE] her mother was being transported to the hospital to see if she had a broken rib because the bruising had become so severe. She was informed the facility did not know how the bruising occurred or the causative agent. Once at the hospital, she reported taking pictures on her cell phone of the extensive bruising to her mother's chest and left arm. The daughter stated the bruising was black and purple and extend across her mother ' s whole chest from the right side of the sternum to the left breast and over under the left arm, with what appeared to her to be two imprints of thumbs or knuckles on either side of the sternum, as they appeared a darker color. The daughter stated that she took the pictures and showed them to the police, who were in the hospital on an unrelated incident. The police told her they would report the incident for investigation. The daughter further concluded from the pictures that someone came up behind her mother and pulled her up roughly to reposition her in the wheelchair and kept her from sliding out of the chair. The daughter stated, the person doing this had to have been large, strong, and impatient as the lift is a two person process. She pointed out two places on the pictures on either side of the sternum with noticeable darker pigmentation and more extensive bruising which she concluded were imprints of knuckles. She stated she had scheduled a meeting with the Director of Nursing (DON) and the administrator of the facility on [DATE] to discuss the incident and see what the facility investigation concluded. The administrative staff told her they were still unsure of how the bruising occurred, but after reviewing the pictures, she stated she thought they agreed with her. Resident #1 ' s daughter provided the surveyors with three pictures of her mother, two were taken immediately after the incident and one the next day. Resident #1's daughter stated she was in the facility often, almost daily, because she wanted to know what care her mother was getting, and she worried about her constantly. Review of Resident #1 ' s Emergency Record dated [DATE] reflected the resident was transported via ambulance from the nursing facility and complained of pain to her chest and ribs when palpated. Inspection findings included ecchymosis to left chest and ribs with symptoms localized most severe in the left upper chest and anterior aspect. Cardiac monitoring was indicated for left rib bruising and radiology imaging ordered, which revealed no overt rib fracture. The final [DIAGNOSES REDACTED]. Resident was evaluated and returned to the nursing facility from the local emergency room . In an interview on [DATE] at 4:17 pm the DON indicated the facility never found a clear reason for the bruising on Resident #1's chest and left arm. She added that the physician's assistant (PA) evaluated Resident #1 on [DATE] and reasoned that someone must have come up behind the resident and bear hugged her to move her up in her wheelchair causing the bruising; however, the notes from the PA were unavailable as he died suddenly before notes were turned in and incorporated into the chart. In an interview on [DATE] at 4:20 pm the Administrator stated the PA assessed Resident #1 on [DATE] and believed the bruising may have occurred from repositioning techniques as if someone came from behind and lifted her back up in her chair. At this time the PA ordered a Geri-Chair for repositioning. The Administrator stated she agreed with the conclusion of the PA. Review of a sign in sheet reflected the in-service entitled Handling and Repositioning of Residents was held on [DATE]. There was no additional follow up to the in-service provided with the exception of spot checks according to the DON. Review of the facility's Policy and Procedures titled Transferring a Resident dated ,[DATE] did not reflect repositioning techniques of a totally dependent resident. The facility provided CMS Form 672 reflected 73 residents who needed assistance with transfers.

Based on interview and record review, the facility failed to follow their written policies and procedures that prohibit the mistreatment, neglect, and abuse of residents and misappropriation of resident's property for 1 of 9 residents ( CR #1 ) reviewed for abuse and neglect. LVN #1 failed to provide services and notify the physician when there was a change in CR #1's respiratory status. These failures affected 1 residents and placed 130 residents at increased risk of abuse and neglect. Findings include: Intake # 5 Record review of the facility ' s abuse prevention program dated [DATE] " our facility is committed to protecting our residents from abuse by anyone including but not necessarily limited to employees, other residents etc. Our abuse prevention program governs: mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, and stress management. The protection of residents during abuse investigations. The development of investigative protocol governing alleged resident ' s abuse, timely and thorough investigation of all reports and allegation of abuse ... " Record review of facility ' s policy on abuse prevention date [DATE] revealed " our residents have the rights to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion " . CR #1 Record review of CR# 1 face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR# 1 ' s care plan dated [DATE] revealed the resident had cognitive impairment as evidenced by the resident scored a 3 out of 15 on the BIMs assessment. He had memory problems and an impaired ability to make daily decisions. The goal was the resident ' s needs would be met. Record review of CR #1 ' s MAR indicated [REDACTED]. Further review of the same MAR indicated [REDACTED]. Further review of MAR indicated [REDACTED]. Administration times documented were 9 AM, 3 PM and 9 PM. Record review of CR # 1 ' s physician's orders [REDACTED]. No time was documented on the order. Record review of CR# 1 ' s nurse's notes date [DATE] at 8:30 A. M., revealed " Resident was given his nebulizer treatment this morning after he got up out of bed. After the nebulizer treatment he was short of breath and weaker. His color was pale. I put him on oxygen at 3 liters nasal cannula per portable tank. His color remained pale but he became more alert. He received a skin tear while being put back in bed by the aide. He went to sleep. He said that it was hurting and told me to stopXXX,[DATE], 56, 24, and 93.4. I put a blanket on him, I turned the heater on. At 2:10 P.M., oxygen tank was out, I replaced the tank. He looked paler; he now mumbles not actually talking. At 2:20 P.M., put on non-rebreather mask, coming around a little, lips are dark in color. At 2:45 P.M., Nurse practitioner called, ordered to send to hospital. At 3:00 P.M., talked with resident ' s daughter, I informed her of the skin tear and the transfer to hospital " . Interview on [DATE] at 1:52 P.M., LVN # 1 said on [DATE], CR#1 was given his scheduled nebulizer treatment before breakfast. He was awake and alert and up in his wheelchair. LVN #1 said one of the aides brought the resident to her and said CR#1 was not waking up. The Resident appeared to be having respiratory distress. She said the Resident was put back to bed. LVN #1 did not know if the resident ate breakfast or Lunch. She stated she put the resident on oxygen at 3 liters and he started coming around and answered yes or no questions. She stated she was monitoring him while she was doing other things in the hall for other residents. LVN #1 said she could not do one on one visits with him. She stated she replaced the oxygen tank when the tank emptied, and there was not an oxygen concentrator she could use in the facility. LVN # 1 said she re-checked the resident's vital signs but they were not documented. She stated she checked his oxygen saturation, but could not recall the time she checked it but that the oxygen saturation was 89%. During the same interview LVN #1 stated when the evening shift nurse came on, she told him about the resident. The evening nurse stated to her that the resident needed a re-breather mask which she said they put on the resident. The evening nurse also suggested they call the physician and send him out because he did not look good. LVN #1 then said she called the doctor about 3:00 pm. She stated she had not sent him to the hospital earlier because he was "kind of coming around." LVN # 1 said she had a Unit Manager and the DON in the facility that day but she did not notify them of the resident ' s condition. Interview on [DATE] at 2:15 P.M., the DON said she was in the building and she heard from staff that resident CR #1 was to be transferred to the hospital due to a change in condition -low oxygen saturation. The DON did not make any personal inquiries following what she heard and did not see the resident. She said the resident ' s physician should have been contacted immediately if a change was identified as well as the resident ' s family. She said the resident should have been transferred to the hospital sooner. Interview on [DATE] at 3:10 P.M., CNA # 1 said the resident was usually alert and oriented, and would make his needs known. She said she came in to work the evening shift on [DATE] and when she got to CR# 1 ' s room, he was still in bed with his eyes and mouth open. She said she was shocked and ran down to the nurse ' s station to inquire what was going on with him. She stated he was blue in colorand seemed like he could not get any oxygen. CNA #1 said LVN# 1 told her he had been like that all morning. CNA # 1 said she told LVN# 1 that CR# 1 was DNR and asked when his last vital signs were checked. LVN # 1 did not respond to all her inquires. Interview on [DATE] at 3:45 P.M., LVN # 2 said he came to work to relieve LVN# 1 on [DATE] when she reported CR# 1 had not been doing well all morning. He stated he asked to go see CR #1 and when he got to his room, CR #1 was in bed, pale and no oxygen was being administered, he said there was a concentrator /tank in the room but it was not on and was not connected to the resident. He said he immediately place him on oxygen while he and LVN #1 got a re-breather, and he asked LVN #1 if the physician had been notified. He said when LVN #1 said no, LVNs #1 and #2 went and called the NP and got an order to send the resident to the hospital. LVN #2 stated CR #1's oxygen saturation was in the low 80s. LVN # 2 expressed shortly after 3:30 P.M., the resident was sent out. He was informed CR# 1 died an hour or two later that day, around 5:00 P.M. at the hospital. The facility census dated [DATE] listed 131 Residents.

Based on interview and record review, the facility failed to develop and implement their policy that prohibited mistreatment, neglect, and abuse of 1 of 9 residents (CR# 1) reviewed for care provided after a change of condition had been identified. On [DATE], before breakfast, CR# 1 was identified to have a change in condition with respiratory difficulty. CR# 1 was not provided continuous oxygen and his respiratory status and vital signs were not monitored for 7 hours as his condition deteriorated. CR# 1 ' s physician was not contacted until 2:45 P.M. Resident #1 was transfered to the hospital at 3:30 P.M. and expired approximately two hours later. This failure affected CR# 1 and placed 131 residents at risk of not receiving services needed and /or prompt transfers when a decline and/or a change in their health status were identified which could cause medical decline and death. Intake # 3 Findings include: Record review of CR# 1 face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR# 1 ' s care plan dated [DATE] revealed the resident had cognitive impairment as evidenced by the resident scored a 3 out of 15 on the BIMs assessment. He had memory problems and an impaired ability to make daily decisions. The goal was the resident ' s needs would be met. Record review of CR #1 ' s MAR indicated [REDACTED]. Further review of the same MAR indicated [REDACTED]. Further review of MAR indicated [REDACTED]. Administration times documented were 9 AM, 3 PM and 9 PM. Record review of CR # 1 ' s physician's orders [REDACTED]. No time was documented on the order. Record review of CR# 1 ' s nurse's notes date [DATE] at 8:30 A. M., revealed " Resident was given his nebulizer treatment this morning after he got up out of bed. After the nebulizer treatment he was short of breath and weaker. His color was pale. I put him on oxygen at 3 liters nasal cannula per portable tank. His color remained pale but he became more alert. He received a skin tear while being put back in bed by the aide. He went to sleep. He said that it was hurting and told me to stopXXX,[DATE], 56, 24, and 93.4. I put a blanket on him, I turned the heater on. At 2:10 P.M., oxygen tank was out, I replaced the tank. He looked paler; he now mumbles not actually talking. At 2:20 P.M., put on non-rebreather mask, coming around a little, lips are dark in color. At 2:45 P.M., Nurse practitioner called, ordered to send to hospital. At 3:00 P.M., talked with resident ' s daughter, I informed her of the skin tear and the transfer to hospital " . Interview on [DATE] at 1:52 P.M., LVN # 1 said on [DATE], CR#1 was given his scheduled nebulizer treatment before breakfast. He was awake and alert and up in his wheelchair. LVN #1 said one of the aides brought the resident to her and said CR#1 was not waking up. The Resident appeared to be having respiratory distress. She said the Resident was put back to bed. LVN #1 did not know if the resident ate breakfast or Lunch. She stated she put the resident on oxygen at 3 liters and he started coming around and answered yes or no questions. She stated she was monitoring him while she was doing other things in the hall for other residents. LVN #1 said she could not do one on one visits with him. She stated she replaced the oxygen tank when the tank emptied, and there was not an oxygen concentrator she could use in the facility. LVN # 1 said she re-checked the resident's vital signs but they were not documented. She stated she checked his oxygen saturation, but could not recall the time she checked it but that the oxygen saturation was 89%. During the same interview LVN #1 stated when the evening shift nurse came on, she told him about the resident. The evening nurse stated to her that the resident needed a re-breather mask which she said they put on the resident. The evening nurse also suggested they call the physician and send him out because he did not look good. LVN #1 then said she called the doctor about 3:00 pm. She stated she had not sent him to the hospital earlier because he was "kind of coming around." LVN # 1 said she had a Unit Manager and the DON in the facility that day but she did not notify them of the resident ' s condition. Interview on [DATE] at 2:15 P.M., the DON said she was in the building and she heard from staff that resident CR #1 was to be transferred to the hospital due to a change in condition -low oxygen saturation. The DON did not make any personal inquiries following what she heard and did not see the resident. She said the resident ' s physician should have been contacted immediately if a change was identified as well as the resident ' s family. She said the resident should have been transferred to the hospital sooner. Interview on [DATE] at 3:10 P.M., CNA # 1 said the resident was usually alert and oriented, and would make his needs known. She said she came in to work the evening shift on [DATE] and when she got to CR# 1 ' s room, he was still in bed with his eyes and mouth open. She said she was shocked and ran down to the nurse ' s station to inquire what was going on with him. She stated he was blue in color and seemed like he could not get any oxygen. CNA #1 said LVN# 1 told her he had been like that all morning. CNA # 1 said she told LVN# 1 that CR# 1 was DNR and asked when his last vital signs were checked. LVN # 1 did not respond to all her inquires. Interview on [DATE] at 3:45 P.M., LVN # 2 said he came to work to relieve LVN# 1 on [DATE] when she reported CR# 1 had not been doing well all morning. He stated he asked to go see CR #1 and when he got to his room, CR #1 was in bed, pale and no oxygen was being administered, he said there was a concentrator /tank in the room but it was not on and was not connected to the resident. He said he immediately place him on oxygen while he and LVN #1 got a re-breather, and he asked LVN #1 if the physician had been notified. He said when LVN #1 said no, LVNs #1 and #2 went and called the NP and got an order to send the resident to the hospital. LVN #2 stated CR #1's oxygen saturation was in the low 80s. LVN # 2 expressed shortly after 3:30 P.M., the resident was sent out. He was informed CR# 1 died an hour or two later that day, around 5:00 P.M. at the hospital. Record review of facility ' s policy on change in condition dated [DATE] revealed in order to maintain the resident ' s safety, a change in condition will be collected and reported in a timely manner. When a change in condition occurs, the nurse shall collect and document/report the following baseline information as needed: vital signs, current level of pain and recent changes in pain level, neurological status level of consciousness, cognitive and emotional status, onset, duration and severity. Before contacting a physician about someone with an acute change in condition, the nursing staff will make pertinent observation and collect information to report to the physician , the nursing staff will contact the physician about a significant change in condition , the nursing staff will contact the medical director when unable to reach the attending physician, the nurse and the physician will discuss the situation and changes to the plan of care be made as indicated and the resident and or responsible party will be notified " . Record review of the facility ' s policy on Abuse prevention program dated [DATE], revealed the residents have the right to be free from neglect. Facility census dated [DATE] listed 131 residents.

Based on interview, and record review, the facility failed to promptly consult with the physician, and notify the resident's legal representative or an interested family member of incidents involving 2 of 9 residents (CR #1 and Resident #1) who were reviewed for notifications of changes in conditions. CR #1's physician was not consulted for 7 hours after a change in the resident's respiratory status had been assessed. Resident# 1 ' s responsible party was not promptly notified of fall incidents she sustained. This failure affected 2 residents and placed 130 residents at risk of not consulting with the physician or making the responsible party or interested family members aware of a change which has the potential of negatively impacting their medical condition and psychosocial well-being. Findings include: Intake # 7 CR #1 Record review of CR# 1 face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR# 1 ' s care plan dated [DATE] revealed the resident had cognitive impairment as evidenced by the resident scored a 3 out of 15 on the BIMs assessment. He had memory problems and an impaired ability to make daily decisions. The goal was the resident ' s needs would be met. Record review of CR# 1 ' s nurse's notes date [DATE] at 8:30 A. M., revealed " Resident was given his nebulizer treatment this morning after he got up out of bed. After the nebulizer treatment he was short of breath and weaker. His color was pale. I put him on oxygen at 3 liters nasal cannula per portable tank. His color remained pale but he became more alert. He received a skin tear while being put back in bed by the aide. He went to sleep. He said that it was hurting and told me to stop. (vital signs) ,[DATE], 56, 24, and 93.4. I put a blanket on him, I turned the heater on. At 2:10 P.M., oxygen tank was out, I replaced the tank. He looked paler; he now mumbles not actually talking. At 2:20 P.M., put on non-rebreather mask, coming around a little, lips are dark in color. At 2:45 P.M., Nurse practitioner called, ordered to send to hospital. At 3:00 P.M., talked with resident ' s daughter, I informed her of the skin tear and the transfer to hospital " . Interview on [DATE] at 1:52 P.M., LVN # 1 said on [DATE], CR#1 was given his scheduled nebulizer treatment before breakfast. He was awake and alert and up in his wheelchair. LVN #1 said one of the aides brought the resident to her and said CR#1 was not waking up. The Resident appeared to be having respiratory distress. She said the Resident was put back to bed. LVN #1 did not know if the resident ate breakfast or Lunch. She stated she put the resident on oxygen at 3 liters and he started coming around and answered yes or no questions. She stated she was monitoring him while she was doing other things in the hall for other residents. LVN #1 said she could not do one on one visits with him. She stated she replaced the oxygen tank when the tank emptied, and there was not an oxygen concentrator she could use in the facility. LVN # 1 said she re-checked the resident's vital signs but they were not documented. She stated she checked his oxygen saturation, but could not recall the time she checked it but that the oxygen saturation was 89%. During the same interview LVN #1 stated when the evening shift nurse came on, she told him about the resident. The evening nurse stated to her that the resident needed a re-breather mask which she said they put on the resident. The evening nurse also suggested they call the physician and send him out because he did not look good. LVN #1 then said she called the doctor about 3:00 pm. She stated she had not sent him to the hospital earlier because he was "kind of coming around." LVN # 1 said she had a Unit Manager and the DON in the facility that day but she did not notify them of the resident ' s condition. Interview on [DATE] at 2:15 P.M., the DON said she was in the building and she heard from staff that resident CR #1 was to be transferred to the hospital due to a change in condition -low oxygen saturation. The DON did not make any personal inquiries following what she heard and did not see the resident. She said the resident ' s physician should have been contacted immediately if a change was identified as well as the resident ' s family. She said the resident should have been transferred to the hospital sooner. Interview on [DATE] at 3:10 P.M., CNA # 1 said the resident was usually alert and oriented, and would make his needs known. She said she came in to work the evening shift on [DATE] and when she got to CR# 1 ' s room, he was still in bed with his eyes and mouth open. She said she was shocked and ran down to the nurse ' s station to inquire what was going on with him. She stated he was blue in color and it seemed like he could not get enough oxygen. CNA #1 said LVN# 1 told her he had been like that all morning. CNA # 1 said she told LVN# 1 that CR# 1 was DNR and asked when his last vital signs were checked. LVN # 1 did not respond to all her inquires. Interview on [DATE] at 3:45 P.M., LVN # 2 said he came to work to relieve LVN# 1 on [DATE] when she reported CR# 1 had not been doing well all morning. He stated he asked to go see CR #1 and when he got to his room, CR #1 was in bed, pale and no oxygen was being administered, he said there was a concentrator /tank in the room but it was not on and was not connected to the resident. He said he immediately placed him on oxygen while he and LVN #1 got a re-breather, and he asked LVN #1 if the physician had been notified. He said when LVN #1 said no, LVNs #1 and #2 went and called the NP and got an order to send the resident to the hospital. LVN #2 stated CR #1's oxygen saturation was in the low 80s. LVN # 2 expressed shortly after 3:30 P.M., the resident was sent out. He was informed CR# 1 died an hour or two later that day, around 5:00 P.M. at the hospital. Resident #1 Record review of Resident # 1 ' s face sheet revealed a [AGE] year old female admitted to the facility on [DATE] and the resident also had a recent re-admission on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident # 1 ' s MDS dated [DATE], revealed the resident had intact cognition of 15 of 15. The MDS revealed no history of a fall prior to admission or during the stay in the facility. Record review of Resident # 1 ' s incident report dated [DATE] revealed the resident had a fall at 8:35 A. M. Resident # 1 ' s Responsible party was notified at 2:55 P.M. Record review of Resident # 1 ' s incident report dated [DATE] revealed the resident had a fall at 3:40 A.M. Resident # 1 ' s Responsible party was notified at 7:00 A.M. Interview on [DATE] at 11:45 A.M., DON said she expect staff to call residents ' responsible party as soon as possible to notify them of incidents involving the residents as well as changes in the resident's condition. She said the resident ' s family should have been notified earlier than 6 hours after a fall. Interview on [DATE] at 4:10 P.M., Resident # 1 said her family was not notified of changes timely. She said most of the time she had to call the family to notify them of any changes and it would always be before the facility would attempt to call a them. Record review of facility ' s policy on change in condition dated [DATE] revealed in order to maintain the resident ' s safety, a change in condition will be collected and reported in a timely manner. When a change in condition occurs, the nurse shall collect and document/report the following baseline information as needed: vital signs, current level of pain and recent changes in pain level, neurological status level of consciousness, cognitive and emotional status, onset, duration and severity. Before contacting a physician about someone with an acute change in condition, the nursing staff will make pertinent observation and collect information to report to the physician , the nursing staff will contact the physician about a significant change in condition , the nursing staff will contact the medical director when unable to reach the attending physician, the nurse and the physician will discuss the situation and changes to the plan of care be made as indicated and the resident and or responsible party will be notified " . Record review of Facility ' s policy on Residents rights not dated did not address the residents right to have their needs/change in condition/incident involving communicated to their physician as well as interested family members. Facility Census dated [DATE] listed 131 residents.

Based on interview and record review, the facility failed to provide new admissions to the facility with timely pain management related to their various conditions for three (3) of eight (8) residents reviewed for pain management (Resident's #2, #3, and #8). A) Resident #8 did not receive pain medication for 10 hours after admission even though he stated he was in pain during the admission. B) Resident #2 did not receive pain medication, although in pain, until the day after admission. C) Resident #3 did not receive pain medication after admission for 3 days even though he stated he was in pain. This failure to provide effective pain management for new admissions contributed to the ineffective pain management for Resident #8 with the potential to affect any new admission with pain medications ordered. The findings include: A) Interview with Resident #8 on 2/21/13 at 7:50 AM reflected he had requested pain medications from the time he was admitted to the facility on [DATE] at 12:30 PM until 10:30 PM that evening when he finally received medication for his right knee replacement surgery. He stated he had told both the nurse aide and the Charge Nurse about his pain, but was told the medication had not come to the facility from the Houston based pharmacy the facility used. Per observation and interview on 2/21/13, Resident #8 was not experiencing any problems with his pain medications since the day of admission. Record review of the clinical record of Resident #8 reflected the Initial Nursing Summary dated 2/14/13 was completed at 2 PM. The resident was assessed as alert and oriented to person, place and time. The resident was documented as having no pain during the assessment. On the Pain Assessment form dated 2/14/13, Resident #8 was documented as complaining of pain to the right leg/knee " recent total knee replacement ...medicated per orders " and that the pain affects his mobility and general activities with sometimes sleep disturbance. Record review of a facility investigation report dated 2/18/13 involving SR #8 revealed the resident complained to the facility administration related to not receiving pain medication from 12:30 PM to 10 PM on 2/14/13. Written statements from LVN #2 documented that he explained to Resident #8 that the pain medication was not at the facility. There was no time listed on the statement related to when this information was shared with Resident #8. Review of a written statement dated 2/15/13 by CNA #1 revealed she had checked on Resident #8 " several times " on 2/14/13 during the 2 PM to 10 PM shift and the nurse had been informed by the aide that the resident was having pain. Further review revealed a written statement from Certified Nurse Aide (CNA) #2 dated 2/15/13 documenting the resident continued to be upset about his lack of pain medication after admission the day before. Interview with CNA #2 on 2/21/13 at 7:50 AM revealed she had given the above statement. She stated the resident was talking normally, but continued to discuss the lack of pain medications provided during his first day at the facility. Interview with the Director of Rehabilitation (DOR) on 2/21/13 at 8:30 AM revealed the Resident had refused to allow his therapy aide to provide services the morning of 2/15/13 stating there was too much pain upon moving his right leg. She stated the resident had been medicated for pain prior to the aide attempting to provide services. She stated there may have been a personality conflict, so she had assigned a different aide to assist Resident #8 and there had been no further concerns. The DOR stated she was aware of the Resident not receiving his pain medication in a timely manner the day of his admission because it was discussed in the morning meetings. B) Record review of the closed clinical record of Resident #2 reflected she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Nursing note dated 2/12/13 at 3:00 AM revealed the resident had a 10 of 10 pain level. She was documented as alert and oriented to person, place and time. The nurse documented she had informed the resident that her medications were ordered on admission, but were not available at the facility at that time. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Resident was documented as being discharged to another facility on 2/19/13. C) Record review of the closed record of Resident #3 reflected he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Initial Nursing assessment dated [DATE] revealed the Resident was in pain upon admission. The Pain Assessment form dated 2/01/13 indicated the Resident was experiencing an aching, stabbing pain to the right hip. The Resident indicated the pain affected his mobility, general activity and quality of life. The Resident was documented as responding to his pain medication. Record review of the Medication Administration Records for January 2013 and February 2013 revealed the first dose of pain medication was documented on 2/03/13. Review of the physician's admission orders [REDACTED]. Neither of these medications was documented as given on 1/31/13 when the resident complained of pain during the admission process. The resident was documented as discharged to another facility on 2/05/13. Interview with the Director of Nursing (DON) on 2/21/13 at 10:45 AM revealed the facility had provided further training to the licensed staff related to pain management after receiving complaints from Resident #8. She stated she had not initiated a system to ensure that all new residents with pain medications had them available as needed for use at that time. According to the DON, the facility contracted with the local pharmacies to get as needed or immediate dosages of required medications. Interview with Licensed Vocational Nurse (LVN) #1 on 2/21/13 at 11:20 AM revealed she performed initial assessments for residents that arrived on Hall 300 of the facility and the unit was mostly Medicare residents. She stated if a resident had as needed controlled pain medications, the nurse was to notify the physician for a prescription for the local pharmacy. She stated depending on the physician, it may be difficult to get the prescription. She stated there were no controlled substances in the Emergency Medication Box maintained at the facility. According to LVN #1, the facility received approximately two to three residents on this wing per week, but the number varied due to availability of the beds.