Every finding on record at Legend Oaks Healthcare and Rehabilitation Center G

Based on interview, and record review, the facility did not ensure treatment and services was provided, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for 1 of 3 residents reviewed for quality of care. (Resident #1)The facility failed to implement treatment orders for Resident #1's right heel as ordered by Wound Care Specialist from 5/11/2026-5/18/2026.This failure could place residents at risk for developing avoidable pressure injuries and the worsening of existing pressure injuries.Findings included:Record review of Resident #1's face sheet, dated 5/23/2026, indicated Resident #1 was a [AGE] year-old female, admitted [DATE], diagnoses included intracapsular fracture of right femur (occurs within the joint capsule of the hip, most often involving the femoral head or neck), Hyperlipidemia (a condition characterized by elevated levels of cholesterol in the blood), Alzheimer's (most common cause of dementia, a condition involving significant memory loss and other cognitive abilities that interfere with daily life), and anxiety (an emotional characteristic by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events). Record review of an admission MDS assessment, dated 5/11/2026, indicated Resident #1 was usually understood and usually understood by others. The MDS indicated a BIMS score of 99 which indicated Resident #1 was unable to complete the interview. The MDS indicated Resident #1 was dependent on staff for toileting, showering, dressing lower body and personal hygiene. The MDS indicated Resident #1 was at risk of developing pressure ulcers/injuries and had 1 deep tissue injury that was not present upon admission.Record review of the care plan, last revised on 5/11/2026, indicated Resident #1 had potential/actual impairment to skin integrity related to suspected deep tissue injury, initiated on 5/11/2026 and created on 5/20/2026. Interventions initiated on 5/20/2026 included offloading boots while in bed, administration of treatment as ordered, encourage good nutrition and hydration to promote healthier skin, use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. During record review of Resident #1's Clinical admission note, dated 5/7/2026, indicated Resident #1 had a surgical wound and redness to her buttocks. The Clinical admission note did not indicate Resident #1 had a pressure area to her right heel. During record review of Resident #1's Baseline Care plan, dated 5/7/2026, Resident #1 had potential for pressure ulcer development with interventions to administer treatments as ordered and monitor for effectiveness, monitor nutritional status, serve diet as ordered, monitor intake and record, notify nurse immediately of any new areas of skin breakdown such as redness, blisters, bruises, discoloration noted during bathing or daily care, and weekly head to toe skin at risk assessment.During record review of Resident #1's progress note, dated 5/11/2026 at 5:45 PM as a late entry, the Treatment Nurse indicated Resident #1 had a new skin issue located on the right lateral heel and was unstageable. The Treatment Nurse indicated the right lateral heel pressure ulcer was present upon admission and measured 1.2 cm x 1.5 cm x 1.8 cm. The Treatment Nurse's progress note indicated the family was present during the assessment.Record review of Resident #1's Initial Wound Care Evaluation and Management Summary, dated 5/11/2026, indicated the chief complaint was, Patient present with a wound on her right heel. The evaluation indicated Resident #1 had an unstageable DTI to the right heel. The right heel wound measured 1.20 cm x 1.50 cm with skin intact with purple/maroon discoloration. The dressing treatment plan on the wound care evaluation summary included for betadine to be applied once daily and as needed. General recommendations included: Reposition per facility protocol, off-load wounds, float heels in bed, and cleanse with wound cleanser at the time of dressing changes. Record review of Resident #1's consolidated orders, dated 5/23/2026, did not indicate any wound care orders on 5/11/2026. Resident #1 did not receive treatment for the pressure area to her right heel from 5/11/2026-5/19/2026. Record review of Resident #1's Wound Evaluation and Management Summary, dated 5/18/2026, indicated Resident #1's unstageable DTI of right heel measured 2.3 cm x 2 cm with skin intact with purple/maroon discoloration. The dressing treatment plan on the wound care evaluation summary included for betadine to be applied once daily and as needed. General recommendations included: Reposition per facility protocol, off-load wounds, float heels in bed and cleanse with wound cleanser at time of dressing changes.Record review of Resident #1's Wound Evaluation and Management Summary, dated 5/20/2026, indicated RP was at bedside. The RP was noted to be upset about the DTI noted on assessment. The Skin assessment on left heel, sacrum and buttock was performed and no active wounds were observed. The wound to unstageable right lateral heel measured 0.5 cm x 1.6 cm with intact purple/maroon discoloration. The dressing treatment plan on the wound care evaluation summary included betadine apply once daily and as needed. General recommendations included: Reposition per facility protocol, off-load wounds, float heels in bed and cleanse with wound cleanser at time of dressing changes. Right heel wound measured 0.5 cm x 0.7 cm with intact purple/maroon discoloration. The wound care orders indicated skin prep once daily and as needed.Record review of Resident #1's consolidated physician orders, dated 5/23/2026, indicated an order initiated on 5/20/2026 to cleanse right lateral heel with wound cleanser or normal saline, pat dry and apply betadine every day shift for wound care. The order also indicated wound care order for right heel with orders to cleanse with wound cleanser or normal saline, pat dry and apply skin prep starting on 5/21/2026. There were no orders for wound care starting on 5/11/2026. During record review of Resident #1's TAR, Resident #1 had the following orders:Right Heel: cleanse with wound cleanser or normal saline, pat dry, and apply betadine every shift for wound care starting on 5/19/2026 and was discontinued on 5/21/2026. Documentation indicated wound care was performed on 5/19/2026 and 5/20/2026.Right Heel: cleanse with wound cleanser, pat dry and skin prep each shift starting on 5/20/2026 and discontinued on 5/21/2026.Right lateral heel: cleanse with wound cleanser or normal saline, pat dry and apply betadine every day shift for wound care starting on 5/21/2026. Wound Care was documented completed on 5/22/2026.Right Heel: cleanse with normal saline, pat dry, and apply skin prep every day shift for wound care starting on 5/21/2026. Wound care was documented completed on 5/22/2026.Record review of Resident #1's Skin Assessment, completed on 5/11/2026, indicated an unstageable pressure ulcer/injury to right heel and a surgical wound to front right trochanter was present at admission. Record review of Resident #1's Skin Assessment, completed on 5/14/2026, indicated there were no new skin issues found on the evaluation and foot evaluation was completed. Record review of Resident #1's Skin Assessment, completed on 5/21/2026, indicated there were no new skin issues found and foot evaluation was completed. During a phone interview on 5/23/2026 at 8:44 AM, RP said Resident #1 was discharged from the facility at 8:00 AM. RP said the treatment nurse observed a new pressure ulcer on 5/11/2026 and did not notify RP. RP said the treatment nurse had come in and provided treatment. RP stated there was a meeting on 5/11/2026 and no one had informed her of any skin issues. During a phone interview on 5/23/2026 at 10:58 AM, RP reported Resident #1 was covered in wounds and she was unaware of them. During an interview on 5/23/2026 at 3:12 PM, CNA A said she provided showers for Resident #1 on Monday, Wednesday, and Fridays. CNA A said Resident #1 had steri-strips (sterile, reinforced adhesive skin closures used to pull edges of shallow cuts, surgical incisions, or lacerations together) in place after her staples were removed. CNA A said Resident #1 did not have any open areas to her to her right hip surgical incision. CNA A said Resident #1 had, what she thought, was a pressure area to her right heel, and stated it was not open. CNA A said if she observed any new areas on a resident, she would tell the nurse and then the treatment nurse. She said she would report it immediately. CNA A said she had not observed any concerns to report to the nurse. CNA A said she had been in-serviced on Abuse and Neglect. CNA A said neglect was if left someone without changing them or providing their activities of daily living. CNA A said the treatment nurse was responsible for ensuring the resident's skin assessments and treatments were completed. CNA A said the charge nurse was responsible for reporting new skin openings to the family. CNA A said a resident could get an infection if an area was not identified or treated. During an interview on 5/23/2026 at 3:44 PM, CNA C said she would report to the nurse or treatment nurse if she observed new wounds or skin issues. CNA C said a resident could get an infection and it could cause problems for them. She said the nurse should be notified as soon as a new skin issue was found. CNA C said the nurse was responsible for notifying the family. CNA C said the charge nurse was responsible for putting in the orders. CNA C said if orders were not put in the computer for wound care, it could affect the residents' health. During an interview on 5/23/2026 at 3:47 PM, LVN D said she assessed Resident #1's skin this morning prior to discharge. LVN D said she administered Resident #1's medications and set up her breakfast tray. LVN D said the family did not want her to have a shower prior to discharge. LVN D said she looked at the dressing in place to her right hip, boots were on bilateral feet with betadine on heel. LVN D said Resident #1 did not have any open areas, heel was not open and the incision was healed. LVN D said Resident #1 went to the Orthopedic Physician on Thursday and he removed her staples. LVN D said the resident was eating well and the family was there for all her meals. LVN D said the treatment nurse made rounds with the Wound Care Specialist. LVN D said the treatment nurse was responsible for entering the new orders and supplements. LVN D said the treatment nurse would report to the family and the charge nurse would report to the family if they were the one who found a new area. LVN D said the MD and family would be notified by nurse who found new area. LVN D said the wound could get worse or get infected if new orders were not entered timely and the family would be mad. LVN D said the treatment nurse was responsible for ensuring the orders and treatments were completed. LVN D said she had not received Resident #1's orthopedic note. During an interview on 5/23/2026 at 3:56 PM, the Treatment Nurse said she worked on 5/11/2026 and she said she puts the orders in the day the Wound Care Specialist was at the facility. The Treatment Nurse said she must have forgotten to put in the orders if they were not in the EMR. The Treatment Nurse said the orders should be put in the next day. The Treatment Nurse said she was responsible for putting the orders in. The Treatment Nurse said it was human error from seeing so many residents. The Treatment Nurse said she was positive the family was present at the time of the visit. The Treatment Nurse said the only reason she did not notify the family members was because they were in the room. She said if the family were in the room, she would document it. She said she had not been documenting but it was a lesson learned. The Treatment Nurse said she was responsible for putting in the orders and notifying the family. The Treatment Nurse said it could negatively impact resident if the orders were not being put in and could delay the healing process. During an interview on 5/23/2026 at 4:07 PM, ADON E said she expected the charge nurse to put in standing wound care orders. ADON E said when the Wound Care Specialist had new orders, the treatment nurse was responsible for entering orders. ADON E said the treatment nurse had 24 hours to put the new orders on the EMR. ADON E said she was not sure when the nurse should notify the family of new treatments or orders. ADON E said she expected the family to be notified by the end of their shift. ADON E said if wound care orders were not entered timely, the wound could get worse and negatively impact on a resident's pain, wound, or infection. ADON E said the treatment nurse was responsible. During an interview on 5/23/2026 at 4:12 PM, the DON said she expected the treatment nurse to enter orders from the Wound Care Specialist within 24 hours. She said the family should be notified when the nurse is available to get all the orders. The DON said she expected the nurses to document the family was notified even if the family was in the room. The DON said she could not speculate on what could happen if orders were not put in the computer. The DON said she identified last week areas the treatment nurse was lacking in on her education and knowledge checks. The DON said the treatment nurse was responsible for ensuring the family was notified and the orders were in the computer. The DON said the CNA should report changes to the charge nurse. The DON said she had completed in-services on identifying and reporting skin breakdown. The DON said if there was a skin issue, it would be on the skin report. The DON said she did not think the treatment nurse knew the time frame the orders needed to be entered in EMR. The DON said her previous treatment nurse quit prior to the new treatment nurse was trained. The DON said the new treatment nurse had been in her role for about 1 month. During an interview on 5/23/2026 at 4:20 PM, the ADM said he expected the nurses to place orders from the Wound Care Specialist in the EMR. The ADM said he did not know when the orders should be placed in the EMR. The ADM said the treatment nurse dealt with the Wound Care Specialist. The ADM said the treatment nurse, ADON, and DON was responsible for putting the orders in. The ADM said he could not tell me what could happen if the treatment orders were not being followed. The ADM said the charge nurse and treatment nurse were responsible for reporting a change in condition or new wound to the family. The ADM said it would be documented in the EMR. The ADM said he expected the nurse to document the family was notified even if the family was in the room.Record review of facility policy titled, Skin and Wound Monitoring and Management, revised 4/2025, indicated, .It is the policy of this facility that: 1. A resident having pressure injury (s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. Purpose.1. Promote interventions that prevent pressure injury development. 2. Promote the healing of pressure injuries that are present .3. Prevent the development of additional, avoidable pressure injury.Facility nursing staff will identify and document in the resident's clinical record.Deep tissue pressure injury: Intact or non-intact skin with persistent non-blanchable deep red, maroon or purple discoloration.Procedure: a. Resident assessment: The nurse responsible for assessing and evaluating the resident's condition on admission and readmission is expected to take following actions.a. Complete Initial admission Record, Braden scale.b. Braden scale for pressure injury risk.c. Identify risk factors.d. Risk factors identified on assessment should be documented.e. Develop an individualized person-centered care plan.f. Skin and wound assessment.j. Treatments per physician order should be documented in the resident's clinical record at the time they are administered. 6. Monitoring.a. Daily via medication administration and treatment administration record.Confirm all orders have been implemented as ordered.Weekly via skin weekly committee.Prepare and maintain skin committee review notes and recommendations in the resident's clinical record.document and implement recommended additions or changes to care plan in the resident clinical record.

Based on observations, interviews, and record review the facility to ensure residents were informed orally of their rights for 8 of 8 confidential residents reviewed for resident rights. The facility failed to ensure residents were provided ongoing communication of their rights during their stay at the facility. This failure could place residents at risk for a decreased quality of life and awareness and execution of their rights. The findings included: A record review of resident council minutes indicated resident rights were not reviewed or discussed for the resident council meetings dated 11/06/2025, 12/04/2025, 01/08/2026, 03/05/2026, or 04/02/2026. Resident council minutes indicated only yes for the meeting on the date of 02/02/2026 and did not indicate what rights were reviewed. During an observation on 04/13/2026 at 3:15 PM of the facility bulletin board, resident rights postings were observed on the wall in English and Spanish. During a confidential interview at an undisclosed date and time, 8 confidential residents indicated staff had not discussed or reviewed their rights with them. 8 confidential residents were unable to verbalize any of their rights as residents. During an interview on 04/14/2026 at 1:22 PM the AD indicated she was not aware she should have been reviewing and explaining residents' rights with them. The AD indicated she believed it was important for residents to know their rights. The AD indicated she had assumed residents already knew their rights. The AD indicated she would be responsible for ensuring residents knew their rights. The AD indicated if residents did not know their rights they were more susceptible to abuse. During an interview on 04/14/2026 at 1:50 PM the ADM indicated all staff were responsible for ensuring residents knew their rights. The ADM indicated he believed there would be no reason a resident would not know their rights. The ADM indicated residents were provided a written statement of their rights in the admission packet. The ADM indicated residents were spoken to about their rights as issues arose. The ADM indicated the risk to residents for not knowing their rights would be a reduction in capability for the facility to determine if there is abuse, neglect, or exploitation. A record review of the facility policy revised 11/08/2024 titled Resident Rights and Responsibilities, Notice of indicated the following: Policy:It is the policy of this facility to inform the resident both orally and in writing of his/her rights as a resident, as well as, the rules and regulations governing the resident's conduct and responsibilities during his/her stay in the facility.

Based on interview and record review, the facility failed to ensure residents were provided reasonable access to receive their mail in a timely manner for 8 of 8 confidential residents reviewed for mail. The facility failed to implement a system to distribute incoming mail daily and ensure residents promptly received their mail. This failure could place residents at risk of a delay in residents' personal correspondence, financial information, or other time-sensitive materials. The findings include: During a confidential group interview at an undisclosed date and time, 8 confidential residents indicated they did not receive mail on Saturdays. 8 confidential residents indicated if they were expecting mail on a Saturday they would expect to receive their mail that day. During an interview on 04/14/2026 at 1:28 PM the AD indicated she was responsible for ensuring residents receive their mail on weekdays. The AD indicated she went to the post office and obtained the mail and delivered it to residents throughout the week. The AD indicated she was unsure if the post office was open on Saturdays to obtain the mail. The AD indicated anybody had the ability to obtain the mail on the weekend. During an interview on 04/14/2026 at 1:58 PM the ADM indicated he was unsure if the post office was open on the weekends for staff to obtain mail. The ADM indicated the AD and the transportation manager alternated weekends to obtain mail. The ADM indicated he felt the risk to residents due to not receiving mail on the weekend would be low and it could cause them to be a little bit depressed if they did not get it for one day. During an interview on 04/14/2026 at 2:21 PM, a Postal Service Employee at the post office indicated post office boxes were available to obtain mail from at any time of day seven days a week and mail was distributed into the post office boxes on Saturdays for anyone with a key to obtain. During an interview on 04/14/2026 at 3:13 PM, the Transportation Manager indicated she was on call every other weekend and went to the post office to obtain mail and distribute it to residents then. The Transportation Manager indicated when she does not obtain and distribute mail the AD was responsible. The Transportation Manager indicated if a resident was expecting mail and did not receive it she would expect them to be upset. A record review of the facility policy most recently updated 06/2017 titled Resident Personal Mail revealed the policy did not address receiving and distributing mail on Saturdays.

Based on observations, interviews and record review the facility failed to make information available to residents and their representatives on filing grievances for 7 of 8 confidential residents reviewed for grievances. The facility failed to ensure residents and their representatives had access to grievance forms and accommodations to file an anonymous grievance. This failure could place residents at risk of unresolved grievances and decreased quality of life. The findings include: An observation on 04/13/2026 at 3:15 PM revealed the facility had no grievance forms available for residents or their representatives freely available. The grievance policy was observed posted on the facility bulletin board and in English only. During a confidential group interview at an undisclosed date and time, 7 confidential residents indicated they were unaware of how to file a grievance. 7 confidential residents indicated they had never seen the grievance form. 8 confidential residents were unaware they could file an anonymous grievance. During an interview on 04/14/2026 at 1:15 PM, the AD indicated all staff were responsible for grievances. The AD indicated she had not reviewed with residents how to file a grievance, but she kept the grievance form in her personal resident council binder. The AD indicated she felt most residents felt free to inform the ADM of their concerns. The AD indicated formal grievances are important because they allowed for a designated person to ensure the issue was resolved. During an interview on 04/14/2026 at 1:31 PM, the SW indicated all staff were responsible for grievances. The SW indicated she had only been employed at the facility for 5 days and would soon like to go to resident council to ensure residents were aware of their right to file a grievance. The SW indicated if a resident wanted to file a grievance anonymously she would not put their name on the grievance, they could place the grievance under her door, or they could call the facility and not leave their name. The SW indicated the risk to residents for not knowing how to file a grievance would include being unhappy about something and the issue not being addressed. During an interview on 04/14/2026 at 1:40 PM, the ADM indicated he was responsible for grievances and residents were to bring their grievances to him. The ADM indicated he had not discussed with the residents how to file a grievance. The ADM indicated he assumed residents knew to go to him if they had a concern and they had been informed of the process prior to his employment at the facility. The ADM indicated he probably should have explained the grievance process to residents. The ADM indicated residents did not have the information for how to file an anonymous grievance. The ADM indicated when the facility received a new admission, he would not go over the formal grievance process but would tell them to come to him or a nurse. The ADM indicated the risk to residents for not knowing how to file a grievance or having the ability to anonymously file a grievance would be allowing issues to go on longer than necessary. During an interview on 04/14/2026 at 2:01 PM, LVN B stated he was unable to find a grievance form. LVN B indicated if a resident wanted to file a grievance he would bring them to the ADM. LVN B indicated if a resident wanted to file a grievance anonymously he would provide them a blank sheet of paper. A record review of facility policy most recently revised 04/2025 titled Grievances indicated the following: PolicyIs is the policy of this facility to establish a grievance process that allows the resident(s) a way to execute their right to voice concerns or grievances to the facility or other agency/entity without fear of discrimination or reprisal. 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 facility stay. The facility will make information on how to file a grievance available to the residents and make prompt efforts to resolve grievances that the resident might have.Procedure:.2. Information is made available to the resident and/or representative and posted in designated locations throughout the facility. Information includes: Resident/resident representative have the right to file a grievance orally, in writing and/or anonymously.

Based on interviews and record review the facility failed to provide, based on the preferences of each resident, activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 8 of 8 confidential residents reviewed for activities. The facility failed to provide activities to meet the residents' interests on the weekends. This failure could place residents at risk for a decline in quality of life and psychosocial well-being. The findings included: A record review on 04/13/2026 at 2:03 PM of the last 6 months, November 2025 through April 2026, activities calendars indicated there were no activities available for residents on Sundays for the months of November 2025, December 2025, January 2026, February 2026, March 2026, or April 2026. Every other weekend there was church available for residents and no activity scheduled for the alternate weekend for the months of November 2025, December 2025, January 2026, February 2026, March 2026, or April 2026. During a confidential interview at an undisclosed date and time, 8 confidential residents indicated they did not have activities on the weekend other than church every other Saturday. 8 confidential residents indicated they would like more activities on the weekend. During an interview on 04/14/2026 at 1:18 PM the AD indicated she was at the facility every other Saturday to assist with providing residents with the scheduled church activity. The AD indicated she got an assistant recently that would be able to assist with the alternating Saturday. The AD indicated residents did not have any scheduled activities for Sundays. The AD indicated she believed it to be okay for residents to not have a scheduled activity on Sundays. During an interview on 04/14/2026 at 1:45 PM the ADM indicated he believed there were weekends he believed had enough activities for the residents. The ADM indicated the resident council informed him of their wish to be provided more activities on the weekends during the September 2025 resident council meeting and he was working on providing these. The ADM indicated the risk to residents for not having preferred activities on the weekends would include a need for socialization. A record review of the resident council minutes for the month of September 2025 revealed the minutes did not include the ADM name signed under Staff Members in Attendance. The resident council minutes did not include any indication weekend activities were discussed. A record review of facility policy revised 07/2007 titled Activities indicated the following: PolicyIt is the policy of this facility to ensure residents have the right to choose the types of activities and social events in which they wish to participate. Procedures:.2. When developing the resident's activity and social care plan, the resident should be given an opportunity to choose when, where, and how he or she will participate in activities and social events. Activities, social events, and schedules are developed in conjunction with the resident's interests, assessment, and plan of care.7. Daily activities, including those on weekends and holidays, are provided, as well as scheduled religious and social activities.

Based on observation, interview and record review the facility failed to ensure a system was established for records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determined that all drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 2 of 4 licensed nurse medication carts (100 and 300 hall carts) observed for pharmacy services. 1. The facility failed to ensure RN A did not sign the controlled substance count sheets for the end of their shift at the beginning of their shift on Cart #300 hall, on 04/14/2026. 2. The facility failed to ensure LVN B signed as receiving the controlled substance count sheets for his shift on Nurses Cart #100 on 04/14/2026. These failures could place residents at risk for medication diversion, administration of incorrect medication and compromised resident safety could place residents at risk of not receiving medications as ordered by the physician.Findings include: During an observation on 4/14/2026 at 1:49 PM, revealed 4/4 medication cart that RN A was signing on and off at the same time of signing on at shift count, The controlled drugs on hand. During an observation on 4/14/2026 at 1:57 PM, revealed 4/4 med cart that LVN B had not signed for receiving at the beginning of his shift on the count sheet, The controlled drugs on hand. During an interview on 4/14/2026 at 1:49 PM with RN A, said she always signed both coming/going slots on the Nurse on and Nurse off at the same time so he would not forget at the end of his shift, she said she thought this was ok to do so she would not forget to sign at the end of her shift, she knew she would be responsible if something happened during her shift, for possible drug diversion. During an interview on 4/14/2026 at 2:00 PM, LVN B said he almost always signed the controlled count sheet when receiving control off the count, he just forgot to do so today, He stated he knew he should sign because he was responsible for the cart and the narcotics it contained and he would be responsible if something happened during his shift. During an interview on 4/14/2026 at 2:30 PM, the Corporate Nurse and the DON said each nurse was to sign the Drug Administration Record Controlled Drug Count Record at the time coming on to their shift and at the time they were going off their shift. The DON said she had in serviced all nurses on the procedure and she was ultimately responsible for monitoring and making sure it was done correctly this could cause a resident not to receive their medication as ordered. During a record review and observation on 4/14/2026 at 2:00 PM, the sign on/off sheet read, signing below acknowledges that you have counted the controlled drugs on hand and have found that the quantity of each medication count is in agreement with the quantity stated on the controlled. Record review of the facility's, undated, policy and procedure titled Narcotic Count reflected It is the policy of this facility to justify amount of narcotics remaining when control of supply is released to nurses coming on duty. Undated document.1. One RN or one LVN/LPN going off duty and one RN or one LVN/LPN coming on duty must count and justify narcotics supply for each individual resident at the change of each shift2. After the supply is counted and justified, each Nurse must record the date and his/her signature verifying that the count is correct.

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 and restore continence to the extent possible for 2 of 3 residents (Resident #2 and Resident #3) reviewed for urinary catheters. The facility failed to ensure Resident #2's foley catheter was secured and/or anchored to prevent complications. The facility failed to ensure Resident #3's suprapubic catheter was secured and/or anchored to prevent complications. These failures could place residents with urinary catheters at risk for damage to the bladder or urethra, dislodging of the catheter, and urinary infections. Findings included: 1.Record review of a face sheet dated 04/15/2026 indicated resident #2 was a [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included dementia (a loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), chronic kidney disease (a long-term condition where the kidneys are damaged and cannot effectively filter the blood), intra-abdominal and pelvic mass (an abnormal growth, swelling, or enlargement in the lower abdomen and/or pelvic region), and obstructive uropathy (blockage in the urinary tract that prevents urine from flowing freely). Record review of a quarterly MDS dated [DATE] noted Resident #2 had a BIMS score of 3 which indicated her cognition was severely impaired. She was noted to be dependent on staff for all activities of daily living except eating. Record review of a care plan initiated on 11/06/2025 indicated Resident #2 had an indwelling catheter with a goal for her to be free of catheter related trauma and urinary infection. Interventions included instructions to secure the catheter to facilitate flow of urine, prevent kinking of tubing, and accidental removal. Record review of physician's orders dated 04/14/2026 indicated Resident #2 had an order dated 07/22/2025 with instructions to monitor the urinary catheter for pulling causing tension every shift. The physician's orders also included an order dated 08/22/2025 to change leg strap (used for securing/anchoring catheter tubing) every week and as needed. Record review of a care plan initiated on 11/06/2025 indicated Resident #2 had an indwelling catheter with a goal for her to be free of catheter related trauma and urinary infection. Interventions included instructions to secure the catheter to facilitate flow of urine, prevent kinking of tubing, and accidental removal. During observation and interview on 04/14/2026 at 10:30 AM, Resident #2 was seen lying on her back in bed with the head of the bed slightly elevated. She was noted to have a foley catheter with the catheter tubing connected to tubing that drained urine into a urine collection bag suspended from the bedframe. There was no slack in the catheter tubing as it extended over Resident #2's right leg, over the edge of the bed, and formed a loop before ending at the urine collection bag. There was no leg strap or other device in place to secure or anchor the catheter tubing to prevent it from being pulled or kinked. An attempt to engage Resident #2 in a conversation about the catheter was unsuccessful. 2.Record review of a face sheet dated 04/14/2026 indicated Resident #3 was a [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses which included obstructed and reflux uropathy, urethral abscess (a rare, severe infection involving a localized collection of pus in the tissues surrounding the urethra), and surgical aftercare following surgery on the genitourinary system. During an interview on 04/15/2026 at 10:12 AM, Resident #3 said he could feel the catheter tubing lying on his leg. He said he tried to be careful not to pull it. He said he did not recall having anything on his leg to keep the tubing from being pulled. Record review of an admission MDS dated [DATE] noted Resident #3 had a BIMS score of 15 indicating his cognition was intact. He was able to voice needs and required assistance with mobility and bathing. Record review of a care plan initiated on 02/19/2026 indicated Resident #3 had a suprapubic catheter with a goal for him to be free of catheter related trauma. The care plan included instructions to secure catheter to facilitate flow of urine, prevent kinking, and accidental removal. Record review of physician's orders dated 04/16/2026 indicated Resident #3 had an order dated 02/13/2026 for suprapubic catheter care every shift with instructions to monitor the suprapubic catheter for pulling causing tension. During observation of wound care on 04/15/2026 at 08:50 AM, Resident #3 was noted to have a suprapubic catheter (a tube inserted into the bladder through a small abdominal incision to drain urine). The catheter tubing was connected to tubing that drained urine into a urine collection bag suspended from the bed frame. There was no slack in the catheter tubing as it extended downward from Resident #3's lower abdomen, over his left leg, over the edge of the bed, and formed a loop before ending at the urine collection bag. There was no device in place to secure or anchor the catheter tubing to prevent it from being pulled or kinked. RN-E performed wound care to the suprapubic catheter insertion site and then asked Resident #3 to turn to his right side. RN-E removed the urine collection bag from the bed frame, passed it over the resident's lower body, and handed it to ADON-C who was on the opposite side of the bed. ADON-C suspended the urine collection bag to the bed frame. RN-E completed wound care and assisted Resident #3 to return to his original position on his back. ADON-C removed the urine collection bag from the bed frame, passed it over Resident #3's lower body and handed it to RN-E who lowered the bag and secured it to the bed frame on that side of the bed. At no time during the transfer of the urine collection bag from the left side of the bed to the right side and back to the left side was there any action taken to prevent the catheter tubing from being pulled. Resident #3 did not voice any discomfort during the process. During an interview with RN-E on 04/15/2026 at 11:00 AM, she said it was her responsibility to ensure urinary catheters were monitored for proper care. She said she assessed urinary catheters for pulling or tension, but could not describe how she would know if a catheter was being pulled or if a catheter was in a position that may place tension on the bladder or urethra. During an interview with the DON on 04/15/2026 at 11:15 AM, she said she expected the nurses to monitor residents with urinary catheters for pulling which could result in tension or pressure on the bladder, tears in the urethra, or obstruction of urine flow. She said the nurses would monitor catheters for pulling by looking for slack in the tubing. Record review of the facility's policy dated May 2007 and last revised November 2017 and titled Catheter Care, Indwelling Urinary reflected the following: Policy: It is the policy of this facility that each resident with an indwelling catheter will receive the necessary care and services related to minimizing the risks and promoting the highest practicable well being. This includes but is not limited to.care planning the specific catheter size with resident specific interventions. Record review of Lippincott's Nursing Procedures, 6th Edition reflected that urinary catheters must be secured to prevent movement and traction on the bladder neck, reducing infection risk and mucosal trauma.

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 one of four medication carts (Hall 100 medication cart) reviewed for labeling and storage. The facility failed to ensure LVN B locked the hall 100 medication cart when it was unattended. This failure could place residents at risk of drug diversion, administration of incorrect medication and compromised resident safety.Findings include: Observation on 4/14/2026 at 2:10 PM revealed the medication cart was at the nurse's station with the drawers closed but was unlocked and unattended for approximately five minutes, with no residents or visitors observed around the medication cart. During an interview on 4/14/2026 at 2:15 PM, the corporate nurse stated the cart should remain locked when unattended and it was left unsecured. During an interview on 4/14/2026 at 2:20 PM, LVN B said he stepped away to talk to the DON about orders for a resident for the medical director and failed to lock his cart. LVN B stated the medication cart should remain locked at all times when not under direct supervision of authorized personnel. The LVN B stated leaving the cart unlocked and unattended was a violation of facility policy and it should have been locked before I stepped away, even for a short time. Record review of the facility's policy titled, Medication Access and Storage (revised 5/2007) reflected: it is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls, The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Resident #27 and Resident #65) reviewed for Infection Control. The facility failed to correctly identify residents who required EBP. The facility failed to provide consistent identification of residents who required EBP. The facility failed to ensure Resident #65 who had 2 (two) surgically inserted drainage tubes was on EBP. These failures could place residents at risk for the development and transmission of communicable diseases and infections. Findings included: 1.A record review of a face sheet dated 04/15/2026 indicated Resident #27 was an [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included dementia and colostomy status. She had no diagnoses to support the use of EBP. A review of a quarterly MDS dated [DATE] noted Resident #27 had a BIMS score of 2 indicating her cognition was severely compromised. She was dependent on staff for most activities of daily living. She was mobile via wheelchair. The MDS did not indicate any factors that Resident #27 would require EBP. A record review of Resident #27's physician's orders did not indicate she was to have EBP. During observations of residents on Hall 400 on 04/13/2026 at 09:15 AM, Resident 27 was noted to have an EBP sign posted at the entrance to her room. There were 2 (two) residents names listed on the doorway nameplate. There was no indication of which of the 2 residents required EBP or if both required it. During an interview with ADON-C on 04/13/2026 at 11:15 AM, she said the EBP sign had been posted at Resident #27's doorway because Resident #27 had a colostomy. She said there was an in-service on 04/10/2026 and she learned colostomies did not require EBP. She said staff forgot to remove the sign from Resident #27's doorway. 2.A record review of a face sheet dated 04/15/2026 indicated Resident #65 was an [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses which included COPD (chronic obstructive pulmonary disease - a chronic lung disease that causes obstructed airflow), surgical after care for pseudoaneurysm (a collection of blood between the layers of an artery or in surrounding tissue) with placement of JP drains (a soft, bulb-shaped surgical device used to remove accumulated fluids from a wound site through gentle suction), pleural effusion (excess buildup of fluid between the thin membranes lining the lungs and chest cavity). A record review of a 5-day MDS dated [DATE] noted Resident #65 had a BIMS score of 6 indicating his cognition was severely impaired. He was dependent on staff for most activities of daily living. The MDS indicated Resident #65 had surgical wounds. A record review of Resident #65's physician's orders indicated he had an order dated 02/20/2026 for EBP due to surgical drains following surgery on the circulatory system. During observations of residents on Hall 400 on 04/13/2026 at 09:27 AM, Resident #65 was noted to have a pink dot beside his name on the door nameplate. There was no EBP sign posted at the entrance to the room. During an observation and interview on 04/13/2026 at 09:32 AM, LVN-F was seen standing in the doorway of room [ROOM NUMBER] on Hall 400. When asked, LVN-F said she did not know what the pink dots on the resident name plates were for. During an observation and interview on 04/13/2026 at 09:33 AM, the AD was seen on Hall 400. the AD said she did not know what the pink dots on the resident name plates were for. During an observation and interview on 04/13/2026 at 09:35 AM, the Transportation Person was seen on Hall 400. She said she did not know what the pink dots on the resident name plates were for. During an observation and interview on 04/13/2026 at 09:40 AM, the PT was seen on Hall 400. When asked, the PT said she did not know what the pink dots on the resident name plates were for. During an observation and interview on 04/13/2026 at 09:45 AM, the DON was noted on Hall 400. She said the pink dots on the resident name plates were placed beside the name of the resident in that room who required EBP. The DON removed the EBP sign at the entrance to Resident #27's room and said Resident #27 did not require EBP without explaining why the sign was posted. The DON said the pink dot beside Resident #65's name on the nameplate meant he required EBP. She said Resident #65 had a sign posted but it must have fallen off. As we walked down the hallway, the DON noted an EBP sign on top of a box on the wall in the hallway and said it was the sign for Resident #65's door. The DON placed the EBP sign at the entrance of Resident #65's room. When asked why 2 (two) rooms on Hall 400 had an EBP sign and a pink dot beside the residents' names, 1 (one) room had an EBP sign but no pink dot to indicate who required EBP, and 1 (one) room had a pink dot beside a name but no EBP sign, the DON said the facility had just started using the pink dots to indicate which resident required EBP. She said the nursing staff working on 04/13/2026 had not been in-serviced on the use of the pink dots. The DON said an EBP posted on the doorway into a resident's room indicated someone in that room required EBP. She said the pink dot on the nameplate identified which resident in the room required the EBP. During an interview on 04/14/2026 at 09:01 AM, RN-E said she was the IP nurse. She said residents who required EBP would have an EBP sign posted at the doorway to their rooms. She said a pink dot would be posted beside the name of the resident in the room who required EBP. She said an PPE caddy would be hung on the outside of the closet door of the every resident who required PPE. She said half of the nursing staff were in-serviced on EBP on Friday, 04/10/2026 and the other half were to be in-serviced the next week. During an interview on 04/14/2026 at 02:01 PM, the DON said she, the ADONs, and the IP Nurse worked together to monitor EBP use. She said they reviewed the 24-hour report daily and checked postings for EBP to ensure EBP were initiated and discontinued as indicated. Record review of the facility's undated policy titled Enhanced barrier Precautions Policy indicated the following: Training and Implementation: Staff Awareness and Training1.All staff members will receive initial training on EBP upon hire and annually thereafter. 2.Training will include identification of when EBP are needed; which residents should be placed in EBP.3.Nursing staff ensures that the resident and staff are aware of need to use EBP.a.Posting outside of roomMonitoring and AdherenceThe Infection preventionist ensures that regular audits of staff adherence to EBP guidelines are conducted. Any deviations from protocol should prompt additional training and education efforts.

Based on observation, interview, and record review, the facility failed to post their most recent survey of the facility in an area of the facility accessible to residents, and family members and legal representatives of residents, in 1 of 1 survey binder. The facility failed to ensure the most recent standard survey dated 02/12/2025 was readily available within the survey binder. This failure could place residents at risk for not having access to current information regarding the facility's compliance with federal and state regulations, limiting their ability to make informed decisions and exercise their rights. The findings include: An observation on 04/13/2026 at 3:25 PM revealed the survey binder located within the facility next to the front entrance. Review of the binder indicated it did not include the results from the most recent standard survey completed 02/12/2025. During an interview on 04/13/2026 at 3:35 PM, the ADM indicated he was responsible for ensuring the survey binder was up to date. The ADM indicated he believed the most recent standard survey to be located within the binder. The ADM reviewed the survey binder and recognized the most recent standard survey was not located inside. The ADM indicated the potential risk to residents would include if a resident requested to review the survey results and he was not present at the facility it would not be readily available. The ADM indicated he understood it was a residents right to review the most standard survey results without having to ask for them. The ADM indicated it was an oversight on his part to not have the most recent standard survey results available for residents to review. During a confidential group interview at an undisclosed date and time, 8 confidential residents indicated they did not have access to the most recent standard survey results and they would like to review them. Record review of a facility policy revised 05/2025 titled Required Postings did not address the requirement to post the most recent standard survey results of the facility in an area of the facility accessible to residents, and family members and legal representatives of residents.

Based on observation, interview, and record review, the facility failed to post the nurse staffing data on a daily basis, in a clear and readable format and in a prominent place, and readily accessible to residents and visitors that included the facility name, the number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care for 7 of 7 days (April 7-13, 2026) reviewed for posting of nurse staffing data. The facility failed to post the required nurse staffing information on 04/07/2026, 04/08/2026, 04/09/2026, 04/10/2026, 04/11/2026, 04/12/2026, and 04/13/2026. This failure could place residents at risk for adverse resident outcomes due to understaffing and loss of public trust. Findings included: During an observation on 04/13/2026 at 08:35 AM, the nurse staffing data for 04/06/2026 was noted to be posted on the wall at the beginning of Hall 300. There was no daily nurse staffing data was posted for 04/13/2026. During a second observation on 04/13/2026 at 09:15 AM, the nurse staffing data for 04/06/2026 was still posted on the Hall 300 wall. There was no posting of the daily nurse staffing data was posted for 04/13/2026 anywhere in the facility. During an interview with ADON-C and ADON-D, they said the nursing staffing data was posted so residents and their families would know how the facility was staffed for the current day. They said the failure to post the nursing staffing data prevented that information from being shared with those who were interested. They said they and the DON worked together to monitor the posting of the nursing staffing data. During an interview with the DON on 04/13/2026 at 10:54 AM, she said the Staffing Coordinator was responsible for posting the daily nurse staffing data. She said she and the ADONs shared the responsibility for monitoring the posting of the nurse staffing information. She said the posting of the nursing staffing data had not been posted for the day of 04/13/2026. When shown the 04/06/2026 date of the nursing staffing data posted on Hall 300, the DON said it had not been posted for a week. During an interview with the DON and the Staffing Coordinator on 04/06/2026 at 11:01 AM, the Staffing Coordinator nodded her head yes when asked if she was responsible for posting the nurse staffing data daily. The DON said the Staffing Coordinator had been filling in by working the night shifts lately. She said the posting of the nurse staffing data was overlooked because the Staffing Coordinator had been filling working the night shifts. A review of the facility's policy dated 05/2007 and titled Staffing Numbers, Posting indicated the following: Policy: It is the policy of this facility to post staffing numbers.1. Post the number of staff working who are directly responsible for resident care.2. To comply with the Benefits Improvement and Protection Act of 2000, the facility must include hours worked by Registered Nurses, Licensed Practical/Vocational Nurses, and Nursing Assistants for each shift.3. Post prominently in a public area in readable font on a surface of at least 8.5x11 inches. The policy did not include any instructions on how often the nurse staffing data was to be posted.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 24 hours after the allegation was made, for 1 of 3 residents (Resident's #1) reviewed for abuse and neglect. The facility failed to report an allegation of neglect on 01/19/2026 to HHSC within 24 hours. This failure could place the residents at increased risk for abuse and neglect.The findings included: Record review of the face sheet, dated 01/29/2026, reflected Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of hemiplegia (paralysis) and hemiparesis (weakness) following a stroke affecting the right dominant side. Record review of the admission MDS assessment, dated 11/17/2025, reflected Resident #1 had clear speech, was understood by others, and was able to understand others. Resident #1 had a BIMS score of 15, which indicated no cognitive impairment. Resident #1 had no signs or symptoms of delirium (sudden, acute and fluctuating disturbance in attention, awareness, and cognition) and there were no behaviors. The MDS reflected Resident #1 was totally dependent on staff assistance for toileting hygiene. Resident #1 was frequently incontinent of bowel. Record review of the comprehensive care plan, dated 11/17/2025, reflected Resident #1 had an ADL self-care performance deficit related to a recent stroke with hemiplegia. The interventions indicated Resident #1 required assistance with toilet use. During an observation and interview on 01/28/2026 beginning at 4:26 p.m., Resident #1 was sitting up in her wheelchair. Resident #1 explained last Monday (01/19/2026) CNA B had an attitude with her. Resident #1 stated she pressed her call light because she needed to be changed. She said she had been given a laxative earlier in the day and was having diarrhea. Resident #1 stated CNA B answered her call light at approximately 6 p.m. and explained that she needed to gather her supplies but would return to get her cleaned up. Resident #1 stated CNA B did not return to her room, so she pressed the call light again. She said when CNA B answered her call light the second time, CNA B stated she only had to change Resident #1 every two hours. Resident #1 stated CNA B refused to change her brief, give her name, and stuck her tongue out at her and rolled her eyes when she walked out of the room. Resident #1 said CNA B kept looking over her shoulder during the conversation, like she did not want someone to walk into the room. Resident #1 stated I had to sit in fecal matter for over an hour and I am human and want to be treated like one. Resident #1 stated she was afraid to press her call light because she did not trust anyone to help her. Resident #1 said she called her family member, and she came up to the facility. She said she had no further contact or interactions with CNA B. The family member was at bedside during the interview. The family member stated she had been at the facility on 01/19/2026. The family member stated Resident #1 pressed her call light around 5:45 p.m. because she needed to be changed. The family member stated CNA B answered the call light around 6 p.m. and explained she had just arrived on shift and needed to gather her supplies. The family member stated she left the facility around 6:20 p.m. and CNA B had not returned to provide assistance. The family member stated she sat in the parking lot for approximately 20 minutes and left around 6:40 p.m. The family member stated she assumed care had been provided because Resident #1 did not call her. The family member stated Resident #1 called her around 7:30 p.m. and was audibly upset and in distress. Resident #1 reported that she had still not been changed, and CNA B came into her room, refused to change her, give her name, and stuck her tongue out at her. The family member stated she immediately came up to the facility, confronted CNA B and reported the allegations to the Administrator. During an interview on 01/28/2026 beginning at 8:26 p.m., CNA B stated she was fairly new to the facility and had started around 01/02/2026. She stated she was still working at the facility but was moved off Resident #1's hallway. She said she had only worked 2 days on Resident #1's hallway. She stated Resident #1 did not normally get on her call light, but she was aware Resident #1 was incontinent of her bowels. CNA B stated on 01/19/2026 around 6:10 p.m., Resident #1's family member reported that Resident #1 had diarrhea and needed to be changed. She said she told Resident #1's family member she had just arrived at work and was going to gather her supplies. CNA B stated she changed Resident #1 around 6:20 p.m. and she had just started having a bowel movement but there was no diarrhea. CNA B said she finished changing Resident #1 and told her she would return later to allow her time to finish having a bowel movement. CNA B stated she returned 35 - 40 minutes later and changed Resident #1 a second time. She said Resident #1 had no diarrhea. CNA B stated she was providing care for another resident when Resident #1's family member started asking her questions in a rude tone. CNA B stated the family member accused her of letting Resident #1 sit in her bowel movement for hours, refusing to introduce herself or give Resident #1 her name, and sticking her tongue out at her and rolling her shoulders. CNA B stated she did not stick her tongue out or roll her eyes. She said she re-introduced herself each time she went into the room. She said the Administrator arrived at the facility, explained the allegations were considered neglect and suspended her pending an investigation. CNA B stated she left the facility. During an interview on 01/29/2026 beginning at 12:05 p.m., the Administrator stated on 01/19/2026 he received a call from Resident #1's family member around 8:30 p.m. He said the family was upset that Resident #1 had several large bowel movements and hadn't been changed for two hours. The Administrator said when he arrived at the facility, Resident #1 reported CNA B had come into her room, stated she would be back and turned off the call light, stuck her tongue out at her and rolled her eyes. The Administrator stated he found CNA B and informed her she was suspended pending the investigation and sent her home. The Administrator stated Resident #1 had no evidence of distress and he felt the allegation was more related to customer service versus neglect, which was why he decided not to report the incident to HHSC. The Administrator was unsure of the actual time it took for Resident #1 to receive assistance. The Administrator stated he completed safe surveys and found no further complaints about CNA B. He said there were no resident complaints about call lights not being answered. He said the nurses performed a skin assessment on Resident #1 with no abnormal findings. The Administrator stated neglect was when the facility did not give care, that resulted in further injuries. The Administrator stated there had to be harm or injuries to have been considered neglect. He stated the abuse policy should have been followed, and he felt like he followed the reporting guidelines. The Administrator stated he referenced the state provider letter on abuse reporting and his policy when determining whether an allegation needed to be reported. He said he could also contact several resources within the company. Record review of the 7 safe surveys, dated 01/20/2026, reflected Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8 felt safe in the facility and had no issues or concerns with the staff members at the facility. Record review of the Abuse: Prevention of and Prohibition Against policy, last revised in April 2025, reflected Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort, or safety, resulted in or could have resulted in, physical harm, pain, mental anguish, or emotional distress. All allegations of abuse, neglect. should be reported immediately to the Administrator. Allegations of abuse, neglect. will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations.

Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accident hazards. The facility failed to ensure Resident #1 had appropriate footwear on while she sat in her wheelchair in the dining room on 1/21/26. This failure could place residents at risk of falls and significant injury. Findings included: Record review of Resident #1's face sheet dated 1/21/26 indicated she was an [AGE] year-old female readmitted to the facility on [DATE] with diagnoses including heart failure, chronic respiratory failure, muscle wasting and atrophy, dementia, lack of coordination, and history of falling. Record review of the MDS dated [DATE] indicated Resident #1 usually made herself understood and usually understood others. The MDS indicated Resident #1 had moderate cognitive impairment (BIMS of 12). The MDS indicated Resident #1 used a wheelchair for mobility. The MDS indicated Resident #1 required substantial/maximal assistance with toileting, showers/bathing, lower body dressing and putting on/taking off footwear. The MDS indicated Resident #1 required partial/moderate assistance with oral hygiene, upper body dressing and personal hygiene. The MDS indicated Resident #1 required set up or clean-up assistance with eating. The MDS indicated Resident #1 required substantial/maximal assistance with tub/shower transfers, toilet transfers, chair/bed-to-chair transfers and with sit to stand. The MDS indicated Resident #1 required partial/moderate assistance with rolling to the left and the right, transitioning from a sitting position to a lying position and lying to sitting on the side of the bed. The MDS indicated Resident #1 could independently wheel herself in her manual wheelchair. The MDS indicated she was incontinent of bowel and bladder. Record review of Resident #1's care plan revised on 1/8/26 detailed she was at risk for falls with actual falls on 11/7/25, 11/11/25, 12/6/25 and 1/8/26. The care plan interventions included, anticipate/meet needs and follow facility fall protocol. Record review of incident reports for Resident #1 for November 2025-January 2026 revealed Resident #1 had falls on the following dates; -11/7/2025- no injuries were found; -11/11/2025- no injuries were found;-12/6/2025- no injuries were found; and -1/8/26- sustained a bruise to face and hematoma to face, Resident #1 was sent to the hospital for evaluation. Improper footwear was not selected as a pre-disposing factor with any of the falls. During an observation on 1/21/26 at 12:05 p.m., Resident #1 self-propelled in her wheelchair (by using her feet) into the dining room. The socks to her feet were red and green with no anti-slip surface to the soles. During an observation on 1/21/26 at 2:05 p.m., Resident #1 sat in her wheelchair in the dining room playing bingo. The socks to her feet were red and green with no anti-slip surface to the soles. The sock to the left foot was slipped down beneath her heel. During an interview on 1/21/26 at 2:15 p.m., RN A said Resident #1 was a major fall risk with recent fall injury and lack of safety awareness. RN A said it was important to ensure Resident #1 had appropriate footwear on her feet. During an interview on 1/21/26 at 2:20 p.m., CNA B said fall interventions for at risk residents included wearing anti-slip socks or shoes. During an interview and observation on 1/21/26 at 2:30 p.m., CNA C said she was the assigned CNA for Resident #1 on the 6:00 a.m.- 6:00 p.m. shift. CNA C said fall interventions for at risk residents included wearing anti-slip socks or shoes. CNA C said Resident #1 should have had anti-slip footwear on to prevent falls and potential injuries. During an interview on 1/21/26 at 3:00 p.m., LVN D said she was the nurse assigned to Resident #1 on the 6:00 a.m.- 6:00 p.m. shift. LVN D said Resident #1 was a significant risk for falls with recent fall from her bed resulting in injury. LVN D said Resident #1 should have had anti-slip footwear on her feet. LVN D not having appropriate footwear on in the dining room could result in additional fall and injury. During an interview on 1/21/26 at 3:05 p.m., ADON E said it was important for Resident #1 to have appropriate footwear on her feet because not having slip-resistant footwear could result in her (Resident #1) falling again. During an interview on 1/21/26 at 4:54 p.m., the Administrator said he expected staff to encourage residents to wear appropriate footwear to decrease fall risk. Record review of the facility policy and procedure dated December of 2023, titled Fall management system, stated, It is the policy of this facility to provide and environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.

Based on observation, interviews, and record review, the facility failed to ensure residents reviewed received reasonable accommodation of needs for 3 of 20 residents (Resident#2, Resident #27, Resident #52) reviewed for resident rights. The facility failed to ensure Resident #2, Resident #27, and Resident #52 had a call light within reach. This failure could place residents at risk of injury that could lead to falls, major injuries, hospitalization , and unmet needs. Findings include: 1. Record review of the face sheet dated 1/15/2025 indicated Resident #2 was a [AGE] year old female and was readmitted on [DATE] with diagnoses including Hemiplegia and hemiparesis following Cerebral Infarction affecting the left non-dominant side (Hemiplegia is paralysis of one side of the body. Hemiparesis is weakness of one side of the body and is less severe than hemiplegia. Both are a common side effect of stroke or cerebrovascular accident), posterior subcapsular polar age-related cataract, bilateral (a fast-growing opacity in the rear of the natural lenses most commonly in people who take steroids or have diabetes), weakness (a quality or state of lacking strength), contracture of muscle, left upper arm (permanent shortening and tightening of muscle fibers). Record review of the quarterly MDS dated ,d+[DATE] indicated Resident #2 was usually understood and usually understood others. The MDS indicated a BIMS score of 06 indicating Resident #2 had sever cognitive impairment. Record review of a care plan revised on 11/7/2022 indicated Resident #2 was diagnosed with cerebral vascular accident (stroke) with hemiplegia with interventions to provide assistance turning and repositioning to keep body in good alignment and to prevent skin breakdown. The care plan revised on 11/7/2022 indicated she was incontinent related to activity intolerance, impaired mobility and was not a candidate for toileting program. The care plan indicated Resident #2 was to remain free from skin breakdown due to incontinence and brief use through the review date. During an interview and observation on 2/10/2025 at 9:35 AM, Resident # 2 said the staff answered her call light, but she never could find it. Resident #2's call light was observed hanging off her bedside table and out of reach. 2. Record review of the face sheet dated 2/12/2025 indicated Resident #27 was an [AGE] year old male and was readmitted on [DATE] with diagnoses including seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movement, feelings, and consciousness) , hemiplegia and hemiparesis (severe or complete unilateral loss of strength or paralysis and weakness in one leg, arm or side of face) following a nontraumatic subarachnoid hemorrhage affecting left non-dominant side (a bleed within the subarachnoid space which is between the brain and the tissue covering the brain) , diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) and muscle weakness (loss of muscle strength) . Record review of the quarterly MDS dated [DATE] indicated Resident #27 was able to make self-understood and usually understood others. The MDS indicated a BIMS score of 12 indicating Resident #27's cognition was moderately impaired. Record review of a care plan revised on 1/20/2022 indicated Resident #27 had ADL self-care performance deficits related to hospitalization for Coronary Artery Bypass Graft (CABG), Cerebrovascular accident (CVA), Congestive Heart Failure (CHF) and chest pains with interventions to assist with dressing, hygiene, toilet use, transfer, and bed mobility with one person assist. During an interview and observation on 2/10/2025 at 9:49 AM, revealed Resident #27 was observed to have deficits to his left side and was unable to lift left arm. Resident #27's call light was placed on the bedside table out of reach his reach. 3. Record review of the face sheet dated 2/12/2025 indicated Resident #52 was an [AGE] year old female and was readmitted on [DATE] with diagnoses including mild cognitive impairment (a stage between normal aging and dementia, with memory loss and trouble with language and judgement), pleural effusion (an excessive collection of fluid in the pleural cavity the fluid-filled space that surrounds the lungs) , chronic kidney disease (gradual loss of kidney function) and diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Record review of the quarterly MDS dated [DATE] indicated Resident #52 was able to make self-understood and usually understood others. The MDS indicated a BIMS score of 15 indicating Resident #52 was cognitively intact. Record review of a care plan revised on 1/2/2025 indicated Resident #52 had ADL self-care performance deficits related to weakness, impaired mobility, and cognitive deficits with interventions for one staff participation to reposition and turn in bed, one staff participation with bathing, dressing, and requires one person to assist with transfers. The care plan revised on 1/2/2025 indicated Resident # 52 was at risk for falls related to weakness, impaired balance, and psychotropic medication use. During an observation and interview on 2/10/2025 at 2:37 PM, revealed Resident #52 was sitting in her personal chair located on the left side of the bed with call light out of reach lying on her bed out of her reach. Resident #52 said she had a recent fall while attempting to obtain a crochet needle that was out of her reach. During an interview on 02/12/2025 at 10:15 AM, CNA F said anyone would be able to answer call lights. CNA F said the CNAs were responsible for ensuring call lights were within reach. She said she rounds on residents every 1-2 hours depending on the resident's needs. She said call lights should be clipped to the bed sheet or blanket within the resident's reach. CNA F said she checked the call lights when she made her rounds and would remind the residents what the call light is for. CNA F said it was important to make sure a resident's call light was within their reach so they can call for drinks, medications, report pain, to ensure they were clean and dry and to make sure the resident was not trying to get up by themselves which could result in a fall. CNA F said a resident's needs would not be met if they could not push their call light button. During an interview on 02/12/2025 at 10:29 AM CNA G said the staff should answer the call light quickly. She said a call light should be placed within resident's reach. CNA G said the staff would not know what they need if the resident was not able to reach call light. CNA G said the CNAs were responsible for ensuring call lights were within reach. CNA G said the facility had residents the staff checked on more frequently. During an interview on 02/12/2025 at 10:36 AM LVN H said call lights needed to be within reach. She said all staff are responsible for ensuring call lights were within reach. LVN H said the staff should make rounds at least every 2 hours if not more. LVN H said residents would yell if they needed help and they know to go check on them. LVN H said a resident would be at risk if they were unable to reach call light if they needed assistance. During an interview on 02/12/2025 at 10:49 AM, the ADON said anyone working the floor and providing care could answer the call lights. The ADON said the CNAs should hand the call light to the resident or clip the call light to a blanket to where the call light remains in place. The ADON said residents who have recliners and chairs in their room should still have access to call light and the CNA should make sure call light is within reach of the resident. The ADON said the resident could fall and not be able to get to their call light. During an interview on 02/12/2025 at 11:02 AM, the DON said call lights needed to be placed within a resident's reach. The DON said the call light needed to be clipped to an area easily accessible to the resident. The DON said if a resident was up in a chair, their call light needed to be accessible. She said everyone was responsible for ensuring the call lights were within reach. The DON said the resident could try to get up by themselves and not have access for assistance for someone to help them. During an interview on 02/12/25 at 11:12 AM, the OM said a resident should always have their call light clipped within reach. He said the staff should have contact every couple of hours even if they do not have contact with resident. The OM said the CNAs and medical staff were responsible for ensuring call lights were within reach to meet the needs of the residents. He said if a resident did not have ability to reach the call light, the staff would not be able to meet the needs, or answer questions the resident may have. Review of a facility policy titled Policy/Procedure-Nursing Clinical revised on 5/2007 indicated Routine procedures .Call Light/Bell . Policy.it is the policy of this facility to provide the resident a means of communication with nursing staff. Procedures: .5. Leave the resident comfortable. Place the call device within resident's reach before leaving the room. If the call light/bell is defective, immediately report this information to the unit supervisor.

Based on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 3 of 20 reviewed for medication storage. (Resident #2, Resident #27, Resident # 163) 1. The facility failed to securely store 3 packets of Thera calazinc barrier cream and a medication cup with a white substance located on Resident #2's beside table. 2. The facility failed to securely store over the counter medication Miconazole Nitrate 2% cream for Resident #27 which was located on the bedside table. 3. The facility failed to securely store prescribed medication Silvadene 400 gm and Adapt stoma powder for Resident #163 which was located on the bedside table. The failures could place residents at risk for health complications and not having received the intended therapeutic benefit of their medications and adverse reaction. Findings included: 1. Record review of the face sheet dated 1/15/2025 indicated Resident #2 was [AGE] years old and was readmitted on [DATE] with diagnoses including Hemiplegia and hemiparesis following Cerebral Infarction affecting the left non-dominant side (Hemiplegia is paralysis of one side of the body. Hemiparesis is weakness of one side of the body and is less severe than hemiplegia. Both are a common side effect of stroke or cerebrovascular accident), posterior subcapsular polar age-related cataract, bilateral (a fast-growing opacity in the rear of the natural lenses most commonly in people who take steroids or have diabetes), weakness (a quality or state of lacking strength), contracture of muscle, left upper arm (permanent shortening and tightening of muscle fibers). Record review of the quarterly MDS dated ,d+[DATE] indicated Resident #2 was usually understood and usually understood others. The MDS indicated a BIMS score of 06 indicating Resident #2 was moderately cognitively impaired. Record review of a care plan revised on 11/7/2022 indicated Resident #2 was diagnosed with cerebral vascular accident (Stroke) with hemiplegia with interventions to provide assistance turning and repositioning to keep body in good alignment and to prevent skin breakdown. The care plan revised on 11/7/2022 indicated she was incontinent related to activity intolerance, impaired mobility and was not a candidate for toileting program. The care plan indicated Resident #2's was to remain free from skin breakdown due to incontinence and brief use through the review date. During an observation and interview on 2/10/2025 at 9:35 AM, Resident #2 was observed to have 3 packets of thera calazinc body shield cream and a medication cup with her name written on the side with white substance in the medication cup located on the bedside table. Record review of order summary report dated 2/12/2025 for Resident #2 indicated an order for Nystatin Powder to be applied to underarms topically three times a day for yeast or rash under arms. 2. Record review of the face sheet dated 2/12/2025 indicated Resident #27 was [AGE] years old and was readmitted on [DATE] with diagnoses including seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movement, feelings, and consciousness) , hemiplegia and hemiparesis (severe or complete unilateral loss of strength or paralysis and weakness in one leg, arm or side of face) following a nontraumatic subarachnoid hemorrhage affecting left non-dominant side (a bleed within the subarachnoid space which is between the brain and the tissue covering the brain) , diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) and muscle weakness (loss of muscle strength) . Record review of the quarterly MDS dated [DATE] indicated Resident #27 was able to make self-understood and usually understood others. The MDS indicated a BIMS score of 12 indicating Resident #27 was moderately impaired. Record review of a care plan revised on 11/8/2022 indicated Resident #27 was at risk for pressure ulcer development with goal to have intact skin, free of redness, blisters, or discoloration with intervention to monitor, document and report to MD PRN changes in skin status such as appearance, color, wound healing, signs and symptoms of infection, wound size, and stage. The care plan also indicated the nurse to be immediately of any new areas of skin breakdown such as redness, blisters, bruises, discoloration noted during bath or daily care. During an interview and observation on 2/10/2025 at 9:49 AM, Resident #27said the ointment on his bedside was for his jock itch. Resident # 27 said the nurses applied it to affected area when he needed it. Resident #27 had Miconazole Nitrate 2 % on his bedside table. During an observation on 2/11/2025 at 9:35 AM, revealed Resident #27 was sitting up in bed eating breakfast during morning rounds. Resident #27 was observed to have Miconazole Nitrate 2% cream on his bedside table. During an observation on 02/12/2025 at 08:33 AM, revealed Resident #27 was sitting up in bed eating breakfast during morning rounds. Resident #27 was observed to have Miconazole Nitrate 2% cream on his bedside table. Record review of order summary report dated 2/12/2025 for Resident #27 revealed the report did not indicate an order for Miconazole Nitrate 2 % ointment for jock itch. 3. Record review of the face sheet dated 2/11/2025 indicated Resident #163 was [AGE] years old and was admitted on [DATE] with diagnoses including Cellulitis of the abdominal wall (a bacterial infection of your skin and tissue beneath the skin), unspecified protein-calorie malnutrition (a lack of adequate calories, protein and other nutrients needed for tissue maintenance and repair), malignant neoplasm of bladder (a common type of cancer that begins in the cells of the bladder) and infection of incontinent external stoma of urinary tract (an infectious complication that affect the urinary tract and related to different types of urinary diversion). Record review of a care plan revised on 2/10/2025 indicated Resident #163 had cellulitis to abdominal wall and pain related to wound to abdomen with interventions to administer antibiotics per MD orders, follow pain scale and medicate as ordered, monitor and report to nurse complaints of pain or request for pain treatment. The Care plan revised on 2/10/2025 also indicated Resident #163 had a urostomy (a surgical procedure that creates an artificial opening (stoma) for the urinary system)with interventions to monitor, record and report to MD signs and symptoms of urinary tract infection, ostomy (a prosthetic device that collects waste from surgically created opening in the abdomen) care as ordered, and enhanced barrier precautions. During an observation and interview on 2/11/2025 at 3:40 PM, revealed Resident #163 had urostomy powder and a blue jar of located on bedside table. Resident #163 said the powder was for his urostomy and the cream was for his abdomen wound and he said he applied as needed. During an observation on 2/11/2025 at 3:40 PM, Silvadene 1% labeled with Resident # 163's name, prescriber and direction to be applied to the area outside the stoma pouch twice daily and cover with a non-adherent dressing. Record review of order summary report dated 2/11/2025 for Resident # 163 revealed the report did not indicate an order for Silvadene or adapt stoma powder. During an interview on 2/11/2025 at 7:45 AM, RN J said she was not sure if Resident #163 could have stoma powder at bedside and she would have to check on that. RN J did not return with an answer by end of medication pass on the stoma powder identified. During an interview on 2/12/2025 at 10:15 AM CNA F said calamine should be kept on the their person. CNA F said she did not know if barrier cream packets could be kept at the bedside. CNA F said medications should not be stored in a resident room. CNA F said she would get the nurse, ADON or DON if a medication was identified. CNA F said no medications should be stored at the bedside. CNA F said it could be a high risk if a medication was not taken on time. She said a visitor, or another person could use the medication and it could be serious and make them sick. CNA F said the nurse was responsible for ensuring medications were stored properly. During an interview on 2/12/2025 at 10:29 AM, CNA G said medications should not be stored at the bedside. She said she would notify the nurse if a resident had medications at bedside. CNA G said it could be harmful if a visitor took the medication or used it incorrectly. CNA G said ointments and creams should not be stored at bedside. CNA G said the packets of barrier cream packets could be stored in a resident drawer and were mainly stored in drawer for residents who cannot get out of bed. CNA G said the nurses were responsible for ensuring medication were stored properly. During an interview and observation on 2/12/2025 at 10:36 AM, revealed LVN H was walking down the 400-hall holding 2 tubes of ointments, Desitin and Miconazole Nitrate 2%. LVN H said she removed ointments from Resident #27's room. LVN H said Resident #27's resident representative visited in the evenings and must have brought the ointments with her. LVN H said the staff usually put it in the resident's drawer. LVN H said the ointments could not be accessible for the resident and the staff sometimes placed the ointments in the closet. LVN H said Resident #27 was incontinent, so he wanted to keep it handy. LVN H said Resident #27 had an order for barrier cream due to excoriation (damage or remove part of surface of (the skin) between his legs. LVN H said she would let the DON know if a new medication was identified. LVN H said the ointments were the same. LVN H said the antifungal was for the groin and the barrier cream was for the buttocks. During an interview on 02/12/2025 at 10:49 AM, the ADON said medications were not supposed to be stored in the room. The ADON said medication such as ointments, creams, eye drops were not to be stored in resident rooms. The ADON said the calazinc packets should not be stored in a resident's room. The ADON said she considered antifungal a medication. She said she would want the CNA to notify the nurse if medications were identified. The ADON said CNAs should not be storing medications and the medications such as creams and ointments should be stored out of accessibility to residents. The ADON said someone with dementia could apply or take the medication incorrectly or they could have an allergy to the medication. The ADON said Silvadene and adapt stoma powder should be stored on the treatment cart. The ADON said the nurse should make sure the nurses and staff completed an inventory of what medications were brought in from the hospital or home. During an interview on 02/12/2025 at 11:02 AM, the DON said medication and ointments should not be stored at a resident's bedside. The DON said the antifungal was considered a medication. The DON said she expected the facility to have an order for medications. The DON said a visitor or other resident could get the medication and have an adverse reaction. She said the medications should be stored on the nurse cart. The nurses were responsible for ensuring medications are stored properly. During an interview on 02/12/2025 at 11:12 AM, The OM (Operation Manager) said the medications such as creams, ointments and eye drops should be stored on the medication cart. The OM said he expected there to be an order for medication and properly store. He said the nurses do shift change and medications are accounted for. The OM said he expected the nurses and staff to report medications identified. The OM said there had been families who had brought in medications into the facility. He said the facility staff had attempted to educate residents and families on protocols and regulations, safety and need to review medications for proper diagnosis and treatments plans. The OM said he would expect antifungal cream to be removed from Resident # 27's bedside and stored on the locked medication cart. The OM said ointments and packets of ointment should be accounted for and no ointments or medication cups with medications should be stored on the resident's bedside table. The OM said there could be harmful effects if medication on resident or visitors. Review of a Medication Storage titled Medication Storage in the Facility policy undated indicated 1. Storage of medication. Policy .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication.

Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 24 residents (Residents #18, #46 and #51) reviewed for infection control practices. 1.The facility failed to ensure CNA G performed proper incontinent care. CNA G wiped from the top of Resident #18's buttocks down towards the perineal area during incontinent care. 2.The facility failed to ensure the proper disinfectant cleaner was used to clean Resident #51's isolation room. Resident #51 had Clostridium difficile (bacteria that causes infection in the large intestine). 3.LVN B did not change her gloves or sanitize her hands after performing catheter care for Resident #46. She touched clean items with her dirty gloves. These failures could place residents at risk for cross contamination and the spread of infection. Finding include: 1.Record review of Resident #18's face sheet, dated 2/11/25, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses which included other reduced mobility, weakness, need for assistance with personal care, muscle weakness, alcohol dependence with alcohol induced persisting dementia (a group of thinking and social symptoms that interferes with daily functioning) and Huntington's disease (an inherited condition in which nerve cells in the brain break down over time). Record review of Resident #18's quarterly MDS assessment, dated 12/2/24, indicated she was usually able to make herself understood and could usually understand others. Resident #18 had a BIMS score of 11, which indicated her cognition was moderately impaired. Resident #18 required maximal assistance with bed mobility and hygiene. Resident #18 was always incontinent of bowel and bladder. Record review of Resident #18's care plan dated 6/27/23 indicated bowel/ bladder incontinence related to confusion, dementia and weakness. Interventions include brief use, uses disposable briefs, change every 2 hours and prn. Chart bowel movement every shift. Incontinent: check as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. Monitor/document for signs and symptoms of UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. During an observation on 02/11/25 at 2:34 P.M., revealed CNA F and CNA G performed incontinent care on Resident #18. While the CNAs performed incontinent care, CNA G wiped from the top of Resident #18's buttocks down towards the perineal area, then CNA F told her, I am going to need you to wipe up on the buttocks. During an interview on 2/11/25 at 2:41 P.M., CNA F said she knew they messed up with incontinent care when CNA G wiped down on Resident #18's buttocks instead of wiping up and away from her perineal area. She said when performing incontinent care, when someone wiped down on the buttocks or intergluteal cleft (the formal term for the groove between the buttocks) that would wash everything toward the perineal area. She said improper incontinent care could cause UTIs. During an interview on 2/11/25 at 2:43 P.M., CNA G said she caught herself after she wiped down on the buttocks, then she wiped upward. She said that was not proper incontinent care and she caught herself after she did it. She said improper incontinent care could place the resident at risk for infections or UTIs. Record review of CNA G's: Clinical Proficiency-Incontinence Care sheet dated 10/21/24 indicated CNA G had met the requirements. The competency was signed by evaluator ADON. Record review of CNA F's: Clinical Proficiency-Incontinence Care sheet dated 1/14/25 indicated CNA F had met the requirements. The competency was signed by evaluator ADON. During an interview on 2/12/25 at 9:44 A.M., CNA C said during incontinent care staff were supposed to wipe the buttocks from front to back. She said improper incontinent care could cause a UTI or some type of infection. During an interview on 2/12/25 at 9:59 A.M., LVN J said improper incontinent care can cause UTIs and that came from E. coli getting in the urinary tract. He said staff should be wiping the residents from front to back during incontinent care. During an interview on 2/12/25 at 10:05 A.M., CNA K said during incontinent care the best practice was to go back not down when cleaning a resident's buttocks. She said a negative effect of improper incontinent care if the resident was a female by wiping down, something could get into her peri area and cause a UTI or sore. During an interview on 2/12/25 at 10:15 A.M., the ADON said she thought CNA F was nervous when she performed the incontinent care on Resident #18. She said when staff wiped down on the buttocks during incontinent care, they were pushing bacteria into the urethra. She said a negative effect of improper incontinent care was a potential for UTIs. During an interview on 2/12/25 at 10:26 A.M., CNA L said during incontinent care of the buttocks staff should wipe from front to back instead of down. She said improper incontinent care can cause UTIs and other infections, due to not cleaning correctly. During an interview on 2/12/25 11:32 A.M., the DON said she expected the aides to perform proper incontinent care. She said improper incontinent care could cause UTIs. 2. Record review of Resident #51's face sheet, dated 02/11/25, indicated he was a [AGE] year-old male, admitted to the facility on [DATE], and readmitted on [DATE]. His diagnoses included cerebrovascular disease (a group of conditions that affect the blood vessels in the brain, leading to disruptions in blood flow and oxygen supply to the brain tissue), enterocolitis due to clostridium difficile (an infection of the colon caused by the bacterium Clostridium difficile), and pneumonia due to mycoplasma pneumoniae (a common respiratory infection caused by the bacterium Mycoplasma pneumoniae) (dated 02/05/25). Record review of Resident #51's quarterly MDS assessment, dated 01/27/25, indicated he had a BIMS score of 08, which indicated moderate cognitive impairment. He did not exhibit behaviors of rejection of care or wandering. He was dependent on staff for many of his activities of daily living, including oral hygiene, bathing, and lower body dressing. He required substantial assistance for other activities of daily living, including roll left and right, sit to lying, and chair/bed-to-chair transfers. Record review of Resident #51's physician's orders, dated 02/11/25, indicated this order: *Room Placement: Single Room Isolation (all services be brought to the resident (e.g., rehabilitation, activities, dining, etc.) every shift for clostridium difficile, mycoplasma pneumonia. The start date was 02/06/25. Record review of Resident #51's care plan, dated 02/03/25, indicated a focus of has clostridium difficile. Interventions included: *Contact isolation: Wear gowns and masks when changing contaminated linens. Placed soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry. *Disinfect all equipment used before it leaves the room. *Educate resident/family/staff regarding preventative measures to contain the infection. During an observation on 02/10/25 at 09:37 AM, there was a red sign on Resident #51's door that stated STOP - Please see nurse before entering. There was an isolation cart outside of Resident #51's room that contained gowns, gloves, and masks. Resident #51 was inside his room sitting in a chair and watching TV. During an interview on 02/12/25 at 10:30 AM, Housekeeping Supervisor K said the housekeepers used the Betco pH7Q Dual disinfectant to clean and disinfect clostridium difficile rooms. He said he was going to look up and see if he could provide documentation that the cleaner killed clostridium difficile. During an interview on 02/12/25 at 10:49 AM, Housekeeper L said she was working on Resident #51's hall this day. She said she had not yet cleaned Resident #51's room, but she was going back to the hall. She said she used the Betco pH7Q dual cleaner to clean for clostridium difficile. She pointed to a bottle of the cleaner on the cart and showed it to this surveyor. During an observation on 02/12/25 at 11:10 AM, this surveyor observed Housekeeper L cleaning Resident #51's room. During an interview on 02/12/25 at 12:34 PM, Housekeeping Supervisor K said he was responsible for ensuring that the facility had a cleaner for killing clostridium difficile. He said the risk to the residents was that someone else could get infected with clostridium difficile. He said they would be getting another product that day. During an interview on 02/12/25 at 01:09 PM, the ADON said she expected the housekeeping staff to use the proper cleaner for clostridium difficile. She said the risk was possible spread of clostridium difficile to other residents. During an interview on 02/12/25 at 01:17 PM, the DON said she expected the housekeeping staff to use a cleaner that would kill clostridium difficile. She said housekeeping staff were responsible for using the proper cleaner. She said the risk was that clostridium difficile could potentially spread to other residents. During an interview on 02/12/25 at 01:22 PM, the Operations Manager said he expected the housekeeping staff to ensure the chemicals did kill clostridium difficile. He said the residents and employees could become sick with clostridium difficile or pass it on. He said the risk was increased for spreading clostridium difficile. He said the risk to the resident was that he could become reinfected. Record review of the following site was accessed on 02/12/25 at 12:00PM, and did not indicate the Betco pH7Q dual cleaner killed clostridium difficile bacteria: * List K: Antimicrobial Products Registered with EPA for Claims Against Clostridium difficile Spores | US EPA Record review of the following site was accessed on 02/12/25 at 12:15PM, and indicated the active ingredient in Betco pH7Q dual cleaner was registered under the name MAQUAT 256-NHQ. *Details for BETCO PH7Q DUAL | US EPA Record review of the following site was accessed on 02/12/25 at 12:15PM, and did not indicate the MAQUAT 256-NHQ cleaner killed clostridium difficile bacteria. *Details for MAQUAT 256-NHQ | US EPA 3.Record review of the undated face sheet indicated Resident #46 was an [AGE] year-old male that admitted [DATE]. Record review of the physician's orders dated 2/11/25 indicated Resident #46 had diagnoses that included: apraxia following cerebrovascular disease (a cognitive disorder that can occur after cerebrovascular disease, such as a stroke), Urinary Tract infection (bacteria gets in the tube through which urine leaves the body), and Extended Spectrum Beta Lactamase Resistance (enzymes that make bacteria resistant to many antibiotics). Record review of the quarterly MDS dated [DATE] indicated Resident #46 had unclear speech, was usually understood, and usually understood others. He had a BIMS of 14 indicating he was cognitively intact. Resident #46 was dependent on staff for toileting hygiene. Record review of the undated care plan indicated Resident #46 had a CVA (Cerebrovascular Accident, a stroke, loss of blood flow to the brain) with aphasia (cannot communicate effectively). The care plan indicated he required the assistance of 1 staff for personal hygiene and had an indwelling catheter related to atonic bladder (bladder muscles are weakened and do not contract effectively), and neuromuscular dysfunction of the bladder (impaired bladder muscle activity due to the disrupted communication between the brain and the bladder itself). The care plan indicated he got a suprapubic catheter 10/13/21. During an observation on 2/11/25 at 3:00 PM, LVN B, CNA C, and the Treatment Nurse donned (put on) their PPE for EBP. Resident #46 was in bed, covered and positioned with pillows. LVN B provided catheter care for Resident #46's suprapubic catheter (a thin, flexible tube inserted through a small incision in the abdomen). LVN B did not change her gloves after completing the dirty procedure. She touched the clean towel with her dirty gloves to dry off his catheter. She touched a clean hospital gown that she covered him with. During an interview on 02/11/25 at 3:08 PM, LVN B said she should have changed her gloves and washed her hands before touching the clean towel to dry the catheter and the gown she laid over him. She said it was wrong of her to do that because she could have transferred bacteria to the resident which could cause infection. She said she was taught to change her gloves and wash her hands after a dirty procedure and before going to a clean one. Record review of a Suprapubic Cath Care Skills Checklist dated 5/22/24 indicated LVN B as proficient with catheter care. This was signed by the previous ADON. During an interview on 2/11/25 at 03:16 PM, CNA C said she noticed LVN B had not changed her gloves after performing catheter care on Resident #46 and had touched clean items with her dirty gloves. She said she did not know she could remind her to change her gloves with a surveyor in the room, so she did not say anything. She said there was a risk of infection to the resident and the staff from touching clean things with dirty gloves. CNA C said she was taught to always change her gloves after a dirty procedure before going to a clean one to prevent infection. During an interview and record review on 2/11/25 at 3:34 PM, the DON provided competencies for Suprapubic Catheter Care - Skills Checklist for LVN B, dated 5/22/24 and signed by the previous ADON. The skills checklist for LVN B indicated she was competent to provide catheter care. The DON said the previous ADON was no longer working at the facility. During an interview on 2/12/25 at 8:13 AM, LVN D said she would always change her gloves and wash her hands after a dirty procedure and before going to a clean procedure. She said if she had performed catheter care, she would immediately change her gloves and wash her hands before touching anything clean. She said touching clean items with dirty gloves was a risk of infection to residents and staff. During an interview 02/12/25 at 10:15 AM, RN E said she sometimes did Foley and incontinent care. She said staff must always change their gloves and wash their hands after a dirty procedure and before touching anything clean. She said touching clean items with gloves that were considered dirty was a risk of infection to staff and residents. RN E said female residents should always be wiped front to back to prevent urinary tract infections or vaginal infections. During an interview on 2/12/25 at 10:34 AM, the DON said she expected all staff to change their gloves and wash their hands after a dirty procedure and before going to a clean procedure. She said using dirty gloves to touch something clean was a risk of transferring bacteria to the resident or staff. She said when wiping a woman, they must always wipe from front to back to prevent urinary tract or vaginal infections. During an interview on 02/12/25 at 11:01 AM, the OM said all staff should change their gloves and wash their hands after a dirty procedure and before going to a clean area to keep from transmitting infection to the residents and staff. He said when wiping a woman during incontinent care, she should be wiped from front to back to prevent urinary and vaginal infections. He said he expected all staff to be accountable when they have done something they should not have, and to learn the correct way for the benefit of the residents. All staff must follow the parameters and the rules. Record review of a Policy/Procedure - Nursing Clinical with a revised date of 5/2007 indicated: Procedures .2. Assist resident to turn on side with back toward you. Expose buttocks area. Wash, using front-to-back strokes, rinse, and dry exposed skin surfaces . Record review of an Environmental Services - Housekeeping Policy with a revised date of 2022 indicated: Policy .Housekeeping and Maintenance services include the cleaning, sanitization, and care for rooms and common areas of the facility to ensure that the facility is a safe for all who reside, work, and visit. 1 .g.Use the proper disinfectant and cleaners when working. These products are labeled and mixed for the intended use. If any questions arise, MDS [MSDS-Material Safety Data Sheets] and product information is available upon request. Record review of an Indwelling Urinary Catheter Care policy with a revised date of 12/2023 indicated: Policy .It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and as needed (PRN) to promote hygiene, comfort, and decrease the risk of infection. 46929 35295

Based on observation, interview, and record review, the facility failed to provide liquids consistent with the resident's needs, for 1 of 24 (Resident #21) residents reviewed for liquid inconsistency, in that: The facility failed to ensure CNA C did not serve ice water on 2/11/25 to Resident #21 who required nectar-thickened liquids. This failure could place residents who have dysphagia at risk for aspiration (breathing on foreign objects). Findings included: Record review of Resident #21' face sheet dated 2/11/25, indicated an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning) and dysphagia oropharyngeal phase (a condition where there is difficulty swallowing during the oropharyngeal phase, which involves the mouth throat and upper esophagus). Record review of Resident #21's quarterly MDS assessment dated [DATE], indicated Resident #21 was usually understood and sometimes understood others. The MDS assessment indicated Resident #21 had a BIMS of 1 and her cognition was severely impaired. The MDS assessment indicated Resident #21 required set-up assistance with eating. The MDS assessment indicated Resident #21 had a mechanically altered diet. Record review of Resident #21's comprehensive care plan revised on 10/30/24, indicated Resident #21 had a potential fluid deficit. The care plan interventions included to encourage the resident to drink fluids of choice, ensure the resident had fluids within reach, and ensure all beverages complied with the diet/fluid restrictions and consistency requirements. Resident #21 had a potential for swallowing problem related history of coughing or choking during meals or swallowing med, holding food in mouth/cheeks (pocketing). Record review of Resident #21's comprehensive care plan dated 12/08/23, indicated Resident #21 had an order for thickened fluids. The care plan intervention indicated all resident fluids should be thickened to nectar consistency. Diet to be followed as prescribe. o Honor resident rights to make personal dietary choices and provide dietary education as needed. o Monitor and report to physician as needed for any sign and symptoms of: decreased appetite, nausea and vomit, unexpected weight loss, complaint of stomach pain, etc. Monitor for shortness of breath, choking, labored respirations, lung congestion. Monitor/document/report to nurse/dietitian and MD PRN for difficulty swallowing, holding food in mouth, prolonged swallowing time, repeated swallows per bite, coughing, throat clearing, drooling, pocketing food in mouth. Record review of Resident #21's order summary report dated 2/11/25, indicated Resident #21 had the following order: *No added salt diet regular texture, nectar thick consistency, with an order start date of 8/23/24. During an observation on 2/11/24 at 12:05 p.m., revealed Resident #21's bedside table in her room had a pitcher filled with ice water. Resident #21 had a sign above the head of her bed and a sign on the wall facing the entrance door that reflected, Nectar Thicken Liquids. During an interview on 02/12/25 09:44 A.M., CNA C said the nurse put a nectar liquid sign in Resident #21's room. CNA C said she put the pitcher of ice water in Resident #21's room, but she had not drunk it. CNA C said she did not know Resident #21 was supposed to drink nectar thickened liquids only. She said she put the little nectar cups of juice in Resident #21's room for her to drink after she was informed of her to drink nectar thickened liquids. She said she had never seen Resident #21 drink the thin liquid water. She said she wondered why Resident #21 had not drank the water. She said if Resident #21 was supposed to drink nectar thickened liquids and she had water without thickening she could had choked. During an interview on 2/12/25 at 9:53 A.M., OT I said if a resident had a pitcher of ice water on their bedside table that was supposed to have nectar thicken liquids, that would not be good. She said most of the time the residents had a sign posted in their rooms. She said if the resident was coughing while drinking the staff would speak to the speech therapist about the resident. She said a negative effect of a resident having thin liquids available, while ordered to have nectar thicken liquids was aspiration, then pneumonia or choking. During an interview on 2/12/25 at 9:59 A.M., LVN J said all staff were responsible for ensuring that the residents have the correct diets and orders were followed. He said a resident on nectar thickened liquids should never have thin liquid water in their room. He said a negative effect of Resident #21 having ice water (thin liquid) was she could aspirate. During an interview on 2/12/25 at 10:05 A.M., CNA K said the aide should have asked the nurse if a resident was on nectar thickened liquids or thin liquids. She said a negative effect of a resident receiving thin liquids with a nectar thickened liquid restriction was the resident could aspirate or choke. During an interview on 2/12/25 at 10:15 A.M., ADON said when the residents come from the hospital, we check to see what type of orders the residents come with such as liquid diets. She usually staff did not put water pitchers in the resident's room that were on thickened liquids, to prevent this from happening. She said a negative effect of Resident #21 having thin liquids and she was on a nectar thicken liquid diet; she could get aspirate pneumonia. During an interview on 2/12/25 at 10:26 A.M., CNA L said the aides usually asked the nurse which residents were on thickened liquids, and they usually had signs in the resident's room if they were on thickened liquids. She said if Resident #21 was to drink a thin liquid and she was ordered to have nectar thick liquids she could aspirate. During an interview on 2/12/25 at 11:32 A.M., the DON said the aides serve the residents' trays, so they should see the residents that were on thickened liquids on the resident's tray card. She said the nurse should had reported the thickened liquids to the aides. She said a negative effect of Resident #21 having ice water was she could aspirate. During an interview on 2/12/25 at 11:36 A.M., the Operations Manager said when the residents came from the hospital and once therapy has evaluated the resident, they communicate the orders needed for the resident. He said a resident on a nectar thickened liquid diet should not had a pitcher with ice water in their room. He said since Resident #21 had already been evaluated and it has been determined that she needed nectar thickened liquids, she should have never had a thin liquid such as ice water, because it could cause choking or aspiration to the resident. Record review of the facility's policy, Nutrition Status Management - Quality of Care, last revised in 12.2023, revealed: .It is the policy of this facility to assess each resident's nutritional status and needs, including medications and medical conditions to ensure that all residents maintain acceptable parameters of nutritional status, such as body weight and other available data, unless the resident's clinical condition demonstrates that this is not possible .

Based on observation, interview, and record review, the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 1 resident (Resident #51) reviewed for respiratory care and services. The facility failed to ensure Resident #51's oxygen concentrator was clean and free of gray debris. This failure could place residents who receive oxygen at risk for developing respiratory complications. Findings included: Record review of Resident #51's face sheet, dated 02/11/25, indicated he was a [AGE] year-old male, admitted to the facility on [DATE], and readmitted on [DATE]. His diagnoses included cerebrovascular disease (a group of conditions that affect the blood vessels in the brain, leading to disruptions in blood flow and oxygen supply to the brain tissue), enterocolitis due to clostridium difficile (an infection of the colon caused by the bacterium Clostridium difficile), and pneumonia due to mycoplasma pneumoniae (a common respiratory infection caused by the bacterium Mycoplasma pneumoniae) (dated 02/05/25). Record review of Resident #51's quarterly MDS assessment, dated 01/27/25, indicated he had a BIMS score of 08, which indicated moderate cognitive impairment. He did not exhibit behaviors of rejection of care or wandering. He was dependent on staff for many of his activities of daily living, including oral hygiene, bathing, and lower body dressing. He required substantial assistance for other activities of daily living, including roll left and right, sit to lying, and chair/bed-to-chair transfers. The assessment further indicated Resident #51 received oxygen therapy while a resident at the facility. Record review of Resident #51's physician's orders, dated 02/11/25, indicated the following order: *o2 (oxygen) at 2-4 liters per minute continuous per nasal cannula. The start date was 02/05/25. Record review of Resident #51's care plan, dated 08/20/24, indicated a focus of Resident #51 was on oxygen therapy related to ineffective gas exchange. Interventions included oxygen via nasal prongs continuously as ordered by physician. During an observation on 02/10/25 at 09:37 AM, Resident #51 was sitting in a chair in his room watching TV. He had oxygen in place via a nasal cannula. The oxygen concentrator was set to 4 liters per minute. The oxygen concentrator filter was dirty with gray debris. During an observation on 02/10/25 at 02:55 PM, Resident #51 was in his room with oxygen in place via nasal cannula. The oxygen concentrator was set to 4 liters per minute. The oxygen concentrator was dirty with gray debris. During an observation on 02/11/25 at 08:27 AM, Resident #51 was in his room with oxygen in place via nasal cannula. The oxygen concentrator was set to 4 liters per minute. The oxygen concentrator was dirty with gray debris. During an interview on 02/12/25 at 01:09 PM, the ADON said Resident #51's dirty filter was likely missed while he was in the hospital. She said the filters should be pulled and cleaned at least once a week. She said she cleaned the filter on 02/11/25. She said the risk to the resident was a possible infection. During an interview on 02/12/25 at 01:17 PM, the DON said she expected the oxygen filters to be cleaned once a week. She said there was an increased risk for infection and poor oxygen flow. She said the nursing staff were responsible for cleaning the oxygen filters. During an interview on 02/12/25 at 01:22 PM, the Operations Manager said he expected the oxygen filters to be clean. He said the nursing staff was responsible for ensuring the filters were clean. He said the risk to the resident was possible harm. He said the contaminants from the air were not being filtered properly and potentially being passed to the resident. Record review of the facility's policy, Oxygen Equipment, last revised May 2007, stated: .It is the policy of this facility to maintain all oxygen therapy equipment in a clean and sanitary manner and to use disposable pre-filled humidifiers, tubing, masks and cannulas for residents receiving oxygen. This equipment is to be discarded after use. The facility will maintain clean tanks, connectors and concentrators . .4. Oxygen concentrator filters will be cleaned with water and detergent every week or according to manufacturers recommendations .

Based on interview, and record review the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 1 of 9 kitchen staff (Dietary Aide A) reviewed for qualified dietary staff. The facility failed to ensure the DA A met the requirements for food handling by obtaining a current and valid Food Handler's Certificate. This failure could place residents at risk of not having their nutritional needs met and placing them at risk for food born illnesses. Findings: During an interview and record review on 2/10/25 at 2:59 PM, the DM provided an undated Active Employee List for the kitchen staff. The list revealed DA A was hired 1/11/21. The DM provided his Food Handler's Certificate that was dated 11/6/22. The certificate indicated it was valid for 2 years. During an interview on 2/10/25 at 3:03 PM, the DM said she would check to see if DA A had a current, valid Food Handler's Certificate. She said his Food Handler's Certificate was not valid after 11/6/24. During an interview and record review on 2/10/25 at 3:53 PM, the DM brought a Food Handler's Certificate for DA A dated 2/10/25. She said he had just completed it. During an interview on 02/11/25 at 11:00 AM, the DM said she was responsible for making sure all staff had their current Food Handler's Certificate. She said she left it up to DA A to get his Food Handler's Certificate in a timely manner. She said she should have made sure he did it and reminded him. She said no one else verified the dietary staff's completion of the food handlers training. During an interview on 2/11/25 3:58 PM, the DON said the policy she provided, Infection Control Policy Food Service/Procedure was the only policy they had regarding Food Handler's Certificates. During a telephone interview on 2/12/25 at 10:03 AM, DA A said he was responsible for getting his Food Handler's Certificate updated as needed. He said he had a lot going on and it slipped his mind. He said he thought there would be a risk to residents, but he did not know what, and did not want to answer the question wrong. He said he updated his Food Handler's Certificate on 2/10/25. During an interview on 2/12/25 at 10:34 AM the DON said everyone that worked in the kitchen should have a current Food Handler's Certificate for safe food handling and to prevent germs and bacteria to the residents. During an interview on 02/12/25 at 11:01 AM, the OM said he expected all staff in the kitchen to follow the parameters and the rules for resident safety and it was unacceptable that DA A did not have a valid Food Handler's Certificate. He said it was the DM's responsibility to make sure DA A had a valid Food Handler's Certificate. Record review of an Infection Control Policy Food Service/Procedure with a revised date of 10/2022 indicated: Policy It is the policy of this facility to prevent contamination of food products and therefore prevent foodborne illness. Procedures 1.Director of food service responsibilities .C.Provide and document personnel education regarding personal hygiene and food handling sanitation . B.Education 1.Basic orientation and annual in-service education will include personal hygiene, hand washing techniques, and food handling sanitation and employee health .

Based on observation, interview and record review, the facility failed to ensure an allegation of abuse was thoroughly investigated for 1 of 11 residents reviewed for abuse. (Resident #1) The facility Administrator, Administrator G, failed to investigate an incident where RN A videoed Resident #1 in his room naked from the waist down. RN A shared the video with other staff. The facility failed to protect Resident #1 from potential further abuse after the allegation. RN A was allowed to work from the date of the incident until she was suspended on 08/22/24. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/26/24 and ended on 08/30/24. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for further abuse, physical or psychological harm or injury. Findings included: Record review of a face sheet dated 10/22/24 revealed Resident #1 was an [AGE] year-old male and admitted on [DATE] with diagnoses including dementia, depression, and anxiety. Record review of a quarterly MDS dated [DATE] revealed Resident #1 was understood and usually understood others. The MDS revealed a BIMS score of 7, indicating severe cognitive impairment. The MDS indicated Resident #1 required supervision with most ADLs. Record review of Resident #1's physician's orders indicated on dated 08/23/24 indicated a verbal order was obtained to monitor for emotional distress every shift for 3 days. Record review of a care plan last revised on 10/12/24 revealed Resident #1 was at risk for impaired thought processes related to a history of dementia. Resident #1 needed assistance with all decision making. Resident #1 had an ADL self-care performance deficit related to decreased mobility and intermittent confusion. The care plan indicated Resident #1 had potential for a behavior problem as evidenced by inappropriate sexual behaviors. There was an intervention to provide privacy and encourage resident to remain clothed per family request. Record review of text messages dated 08/02/24 at 6:14 p.m., indicated texts between HR K and Administrator G. The texts indicated HR K wrote, .And ANOTHER note, I don't know who, how or where it originated from but there has been a video taken of (Resident #1) with no pants on and making its way around the building. Administrator G responded, Oh no! If you're still there, will you mention to one or two of the staff at the nurse's station that any videos taken of residents against their will can give family members a foot hold to sue whoever has the video. HR K responded, I left unfortunately but I was told over the phone, not in person at the facility or I would have said just that and how it's not funny. Administrator G responded, Mmm, ok. I'll mention it to (the Treatment Nurse). Record review of a text message dated 08/02/24 at 6:38 p.m., to the Treatment Nurse from Administrator G indicated, Hey, I just got word that there's an inappropriate video of (Resident #1) going around the facility. Will you mention to the staff that any videos taken of residents against their will can give family members a foot hold to sue whoever has the video. It has happened to our sister facility . Record review of a Grievance Resolution Form dated 08/23/24 indicated Resident #1 was involved in a video without his knowledge. The report indicated the compliance department was involved and notified administration. Record review of a Progress Note dated 08/23/24 indicated, SW (Social Worker) visited with resident (Resident #1) this afternoon .SW noticed no change in his mood or behavior after he was notified of the incident. He continues to show confusion, per his usual state. He states I am OK. I am not going to let this effect my life. He is agreeable to speaking with (psych services). SW has sent in a referral for evaluation and spoke with .counselor, re: the incident. SW will continue to monitor resident and will assist further as needed. The note was signed by the Social Worker. Record review of Nurse's notes for Resident #1 dated 08/23/24 - 08/28/24 indicated Resident #1 was monitored for mood and distress. The notes did not indicate Resident #1 had a change in mood or emotional distress. Record review of an Investigation Summary and Timeline report dated 08/30/24 indicated the DON was notified of the allegation of abuse on 08/22/24 at approximately 5:00 p.m. related to the conduct of RN A. The allegation suggested that the nurse had taken an unauthorized video of a resident. RN A was immediately suspended at the time it was reported, pending investigation. During the interview process, it was confirmed that RN A had taken a video of a resident while in his room The resident was not wearing pants and his genitals were visible. The Investigation Summary and Timeline indicated that Resident #1 had been interviewed by Administrator G and had knowledge of the video at the time of the interview. The Investigation Summary and Timeline report indicated RN A was terminated in person on 08/26/24. The report indicated the police were notified and the RP requested to press charges against RN A. Record review of a Provider Investigation Report dated 08/23/24 indicated that on an unknown date RN A took an unauthorized video of Resident #1. The investigation findings were confirmed. Record review of an interview of RN A dated 08/23/24 at 9:30 a.m. indicated she had taken a video of Resident #1. She stated Resident #1 had been in his room with his roommate. She said it had been reported to her by someone in therapy that they smelled smoke in the residents' room. She said she went to the room and Resident #1 was leaning over his roommate and his genitals were rubbing on the roommate. She stated the video showed Resident #1's backside, naked from the waist down. She said she showed the video to LVN C. She said the purpose of filming the video was to show LVN C the residents behavior. She stated, .I shouldn't have done that. I should have verbally told the nurse or done a progress notes. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by RN A. On 10/22/24 at 11:30 a.m., an attempt was made to reach RN A by telephone. There was no answer. A detailed message requesting a return call was left on voicemail. Record review of an interview of LVN C dated 08/23/24 at 10:10 a.m. indicated that she knew about and had seen the video. She said she had seen the video. She said it was of Resident #1 walking over to his roommate. She said Resident #1 only had a shirt on. She said she just saw the back of Resident #1. She said she saw his buttocks. She said he was bending over to do something, and she could see his genitals hanging down. She said RN A had shown her from her phone. She stated RN A said, Oh my God, look what (Resident #1) did. She said RN A thought it was funny. She said she did not report the video. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by LVN C. Record review of an interview of the Transport Aide dated 08/23/24 at 10:20 a.m. indicated the Transport Aide was aware of and had seen the video. She said the video was shown to her by RN A. She said the video was of Resident #1 walking with a shirt on. She said she could see Resident #1's genitals. The interview indicated that the Transport Aide asked RN A why she had the video and RN A said something to her about when he was younger, he probably had big balls. The Transport Aide said she had seen the video weeks ago. The interview indicated the Transport Aide did not report the video to anyone and when asked why she said, I know I should have. I don't know why I didn't. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by the Transport Aide. During an interview on 10/22/24 at 3:34 p.m., the Transport Aide said she walked in one morning. She said RN A said to come see the video and said, it's really funny. She said she did not understand why RN A would have even filmed the video. She said she watched the video on RN A's phone, and it was never sent to her. She said she thought the video was shown to her in July 2024. She said the video was inappropriate. She said on the video she saw Resident #1 over by the air conditioner. She said RN A said, Look at his balls going back in forth, I bet when he was younger, he was bigger. Record review of an interview of CNA D dated 08/23/24 at 10:20 a.m. indicated CNA D was aware of the video and that she had seen the video. She said it was both shown to her and sent to her via text by RN A. She stated that on the video Resident #1 was standing by his roommate with no pants or underwear on, just a shirt. Resident #1 leaned over to help his roommate and she saw his buttocks, penis, and scrotum. She said it had been less than a month since she had seen the video. She said she did not report the video to anyone. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by CNA D. Record review of an interview of LVN E dated 08/23/24 at 10:20 a.m. indicated LVN E had heard about the video but had not seen the video. He stated it had been about a month since he had heard about the video. He said he heard there was a video of Resident #1's genitalia. He said RN A had told him about the video. He said he thought he should have reported the video but did not report the video. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by LVN E. Record review of an interview of the Staffing Coordinator dated 08/23/24 at 11:05 a.m. indicated the Staffing Coordinator became aware of the video on 08/22/24. The Staffing Coordinator stated RN A came to the office and stated that compliance had called her about a video she had taken of one of the residents and she was scared and didn't know what to do. The Staffing Coordinator indicated she had not seen the video and had only heard gossip about the video. She said the staff that were gossiping did explain what was in the video. She said she did not report what was in the video because it was just gossip. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by the Staffing Coordinator. During an interview on 10/22/24 at 11:42 a.m., the Staffing Coordinator said she was in the hallway on a day in August 2024. She did not remember the date. She said RN A pulled her into the office and said compliance had reached out to her and she did not know what to do. The Staffing Coordinator said RN A was scared. The Staffing Coordinator said RN A said, I think they are calling me about the video. The Staffing Coordinator said she had heard rumors about the video but was not sure if those rumors were true. She said she has never seen the video. She said she heard there was a video out of a resident that they had at the time. She said she did not know any details. She said RN A did not tell her what was on the video or show it to her. She said she reported the incident to the DON after RN A had come into her office. Record review of a telephone interview of the Treatment Nurse dated 08/23/24 at 11:15 a.m. indicated the Treatment Nurse was aware of and had seen the video. She said it was shown to her right before she went on maternity leave. She said in the video she could see Resident #1's behind and his scrotum between his legs. She said RN A had shown her the video. She said it was on RN A's phone. The Treatment Nurse said she had mentioned the video to Administrator G and ADON H. She said she may have reported it the next day but could not remember. She stated that RN A thought the video was funny and was showing staff. She said she told RN A that the video was inappropriate, and she should not be videoing the residents. The interview was conducted and signed by the DON and the Clinical Resource Nurse. During an interview on 10/22/2024 at 1:06 p.m., the Treatment Nurse said she went on leave in August 2024 . She said it would have been the middle of August 2024. She said RN A did show her the video. She said RN A did not send her the video. She said RN A stopped her in the hall and said, Hey look at this. She said you could see Resident #1 and his roommate messing with the air conditioner. She said Resident #1 only had a shirt on. She said you could see his scrotum. She said the video was from behind and she was not sure if you could see the resident's penis. She said it did not appear Resident #1 was aware he was being videoed. She said RN A was laughing about the video. She said she told RN A it was inappropriate, and RN A said, I just thought it was funny. She said she did report it immediately to the previous ADON H that and told Administrator G the same day. She said she told Administrator G on 07/30/24 or 07/31/24. She said Administrator G told her he would address it at the next all staff meeting. Record review of a police Incident Report, dated 08/23/24 indicated Administrator G was the reportee. The report indicated the offense was solicitation to commit - invasive visual recording in bathroom/changing room. The report indicated RN A was the offender. The report indicated the officer spoke with Administrator G and the DON. The report indicated the DON explained that RN A recorded a patient in secret. The report indicated Resident #1 liked to walk around in the nude and RN A had secretly recorded Resident #1 and sent the video through text to RN B and made jokes about Resident #1. RN A showed her co-workers the video while making fun of Resident #1. The officer asked RN B if she still had the video and was told that she had deleted it. The report indicated on 08/27/24 It was concluded by (the facility) that (RN A) had acted inappropriately by recording (Resident #1) and was subsequently terminated for that reason. According to the interviews, (RN A) was distributing the video to other employees and making comments like, When he was younger, he probably had big balls and Look what you're missing out on. RN A herself was interviewed and stated that her reasoning for recording (Resident #1) was to provide his nurse with information on his behavior. During an interview on 10/22/24 at 9:28 a.m. a family member of Resident #1 said the incident of RN A videoing Resident #1 had been reported to the police. He said the investigating officer was Officer J. He said RN A took a video of Resident #1 and shared the video with her co-workers. The family member said they had not personally seen the video. They said Officer J had seen the video. He said Officer J had interviewed some of the facility staff at the police department and had taken several phones. The family member said one of the phones had produced the video. The family member said they did not know which one had. The family member said the facility was aware of the incident in July 2024. The family member said they were not notified of the video until the end of August 2024. The family member said Resident #1 had no memory of the incident. The family member said Resident #1 cannot even remember what he had for breakfast. During an interview and observation on 10/22/24 at 1:30 p.m., Officer J said nursing home staff did not report the video to the police department until a month after it was recorded. He said then the following week, Resident #1's family had reported the video to the police department. He said the first report was made on 8/23/2024. He said review of the video indicated a create date of 7/26/24. He said the police department still had custody of CNA D's and RN B's cell phones. He said they each gave consent for their phones to be searched. He said the video was eventually found on RN B's cellphone. He said on some of the phones there were text messages from the staff members and RN A discussing what Resident #1 might have looked like when he was younger. The video was observed in Officer J's office. The video showed Resident #1 from behind. Resident #1's roommate was sitting in a chair. Each resident had their backs to the camera. Resident #1 had on a polo type shirt. He was naked from the waist down. His buttocks and testicles were visible. At one point in the video, Resident #1 walked over to his roommate and bent over as if to help him with something. When the resident bent over it further exposed his testicles. In the background, there was heard a female voice laughing off and on throughout the video. At one point the female voice said, What is he doing? followed by more laughter. During an observation on 10/22/24 at 2:00 p.m., a video of RN B being interviewed by Officer J revealed RN B stated RN A had sent the video to a few people. RN B said the video was, inappropriate to say the least. RN B said RN A sent the video to her between 07/21/24 to 07/28/24. RN B said she had deleted the video from her phone after she found out that compliance had called RN A. RN B said she had deleted text messages from her phone also. During an interview on 10/23/24 at 8:25 a.m., RN B said she went on vacation for a whole week. She said she then tested positive for Covid and was off another week. She said texted RN A to ask what she had missed at work. She said RN A said, Hey I'm about to send you a video. She said she watched most of the video but not all of it. She said this was normal behavior for Resident #1 and she had seen this behavior daily. She said she felt the video was inappropriate. She said she thought the video was meant to be humorous. She said she thought she typed back, LOL. She said after that she did not think anything else about the video. She said she was sick, and she really did not give it much thought. She said RN A texted her and told her she had sent the video to several other people. She said she did not know the date the video was sent to her, but it was towards the end of July 2024 because she was home sick. She said Resident #1 had a shirt on and nothing below. She said he was walking away from the camera. She said that was as far as she watched. She said she could see his buttocks. She said she did not have her glasses on and did not see his testicles. She said around 8/28/24 she did have a meeting with Compliance. She said she had already deleted the video from her phone. She said now the police had her phone. She said it was sent to forensics and they found the video on the phone. During an observation on 10/22/24 at 2:10 p.m., a video of CNA D was being interviewed by Officer J. CNA D said she was shown the video in the hallway right after RN A had come out of Resident #1's room. CNA D said that at the nurse's station RN A was showing the video to LVN C, LVN E, and herself. During an interview on 10/22/24 at 4:20 p.m., CNA D said RN A sent the video to her the day she recorded the video. She said this date was 7/27/24 on her birthday. She said the resident's roommate was in his wheelchair over by the air conditioner. She said Resident #1 was standing over him with a polo type shirt on and was naked from the waist down. She said she could see his buttocks, testicles, and his penis. She said RN A did not tell her why she took the video. She said she could not remember the context of her conversation with RN A. She said she could not remember if she saw all of the video, but she did feel it was inappropriate. She said she did not report the video to anyone. She said she was not aware of anyone else seeing the video. She said RN A never showed the video to LVN C, LVN E, and herself at the nurse's station. During an interview on 10/22/24 at 2:38 p.m., LVN C said RN A just showed her the video to show her what he was doing. She said the video was just the back of Resident #1 walking over to his roommate with just a shirt on. She said you could not see his face. She said you could see his testicles from behind. She said the video was never sent to her. She said she was at her medication cart when RN A showed her the video. She said LVN E and CNA D were at the facility but were not present when she watched the video. She said the resident's behavior was not a shock to her because he did stuff like that all the time. She said the video was inappropriate and was not necessary. She said RN A was laughing and said, I can't believe this, look at him. She said she did not report the incident. She said at the time she did not think RN A was going to do anything with it. She said at the time she did not think about it reporting it. She said she was not sure of the date the video was taken. She said she felt RN A showed it to her immediately after it was recorded. She said Resident #1 had dementia and would not remember the incident. She said one time he had even walked down the hall with only a shirt on. During an interview on 10/22/24 at 3:24 p.m., PTA L said she was aware RN A took a video of Resident #1. She said RN A showed her the video on her phone. She said she saw Resident #1 in his room naked from the waist down. She said he had only a shirt on. She said he was walking around the room. She said as soon as she saw it, she quit watching the video. She said she did not know if it was the day, RN A took the video. She said she worked at different facilities and was not sure of the day. She said residents across the hall had complained about Resident #1 walking around naked. She said she told RN #1 about the complaint and that was when she showed her the video. She said after viewing the video she did not report it to anyone. She said she did not know why. She said the video made her uncomfortable. She said, I just didn't. I don't know why. I just didn't want that in my brain. She said when RN A showed her the video she was laughing. She thought it was funny. She said Resident #1 was not aware the incident happened. During an interview on 10/22/24 at 3:56 p.m., Administrator G said what occurred was HR K informed him that a video was going around. He said that was either 7/31/2024 or 8/2/2024. He said he thought it was in August 2024. He said he could not remember if she gave him details of the video. He said the allegation did not hit his abuse and neglect radar. He said about two weeks later the DON was informed of the video and communicated the details the video to him and it was reported. He said RN A was suspended immediately and never brought back from suspension. He said he did send a text to the Treatment Nurse on 08/02/24. He said he did say the video was inappropriate. He said he just did not realize how bad the video was or the response would have been completely different. He said he had never seen the video. He said he left the facility sometime in August 2024. He said he was given the option to resign. During an interview 10/22/24 at 4:12 p.m., the Social Worker said she was not even aware of the video until compliance got involved. She said she usually did a checkup with residents after any incident. She said she did safe surveys and there were no concerns. She said she did talk to Resident #1. She said Administrator G had just come out of his room, so the incident was fresh on Resident #1's mind. She said he did not seem upset. She said he did say, I just don't know why someone would do something like that. I'm not going to let it affect me. She said she did get an order for psychology services to check on him. During an interview on 10/23/24 at 8:50 a.m., ADON H said she quit working at the facility on approximately 8/12/24. She said she became aware of the video in July 2024 on a Wednesday. She said the Treatment Nurse had told her. She said she told the Treatment Nurse that she needed to report the video to the DON and Administrator G. ADON H said she reported the video to Compliance on 8/3/24 at 2:00 a.m. She said therefore she was told about the video on 7/31/24. ADON H said she never saw the video. She said the Transport Aide did tell her on 08/09/24 that she had seen the video. She said she quit working at the facility because she felt things were not being addressed. She said there were a few other reasons. She said she understood the facility did not want a tag, but they had to do the right thing. She said she knew the DON was made aware of the video on 7/31/24 and HR K told her again on 8/12/24. During an interview on 10/23/24 at 9:14 a.m., HR K said she found out about the video on 8/2/24. She said ADON H told her about the video. She said RN A was going around showing everyone videos of Resident #1 walking around in his room butt naked. She said she immediately texted Administrator G. She said he said he texted her back and Oh no that is really bad. The family could sue us. Could you please tell the nurse's that is not funny, and they should not be doing that? She said nothing happened after that. She said there was no investigation. She said she reported it to the DON on 8/12/24 and voiced her concerns about nothing happening. She said, and still nothing was done. She said she never saw the video. She said she was told by multiple people it did exist and what it consisted of. During an interview on 10/23/24 at 9:31 a.m., the DON said she first became aware of the video approximately 2 days before she reported the incident to the state. She said HR K told her but did not tell her any details about the video. She said prior to 8/21/24 she had not even heard of the video. She said she was on vacation 7/30/24 - 8/5/24. She said the video was not reported to her during that time. She said on 8/22/24 she became of aware of the content of the video. She said she was told by the Staffing Coordinator. She said the Staffing Coordinator told her there was a video of Resident #1 with his genitals exposed and that RN A had taken the video. She said she suspended RN A immediately. She said she discussed the video with the Administrator G. She said he told her he had no idea about the video. She said she went back to HR K and asked her if she had reported the incident to Administrator G. She said HR K showed her a text message showing that she had reported the video to Administrator G. She said the text was dated 8/2/24. She said to her knowledge there was no investigation started by Administrator G. She said she began the investigation herself on 8/23/24. She said her investigation concluded that RN A had taken the video of Resident #1 and had shown multiple co-workers. She said RN A was terminated on 08/26/24. She said she had not seen the video. She said all staff that had knowledge of or saw the video was given final written warnings for failure to report. She said once she heard the content of the video, she felt it was abuse. She said she felt it should have been reported and investigated right from the very beginning. She said she did talk to Resident #1 about the video. She said he did not remember the incident unless it was brought up by staff. She said she did feel like this was a dignity issue. She said he had been the mayor at one time. She said he was a photographer. She said he could not help his behavior. During an interview on 10/23/24 at 1:30 p.m. RN B said if this happened to herself or a family member, she would feel awful. She said, I would be so mad. During an interview on 10/23/24 at 2:21 p.m., a family member of Resident #1 said in the condition of dementia or Alzheimer's they would not know if this had happened to them. The family member said if they did know, they would feel it was demeaning or demoralizing and against all privacy. They said they thought the whole thing horrible. They said Resident #1 had been a very private but public person. The family member said Resident #1 was the mayor at one time. The family member said Resident #1 never discussed the birds and bees with them because he was a private person. The family member said Resident #1 would not have liked this at all. During an interview on 10/23/24 at 2:43 p.m., the Social Worker said if this happened to her or a family member she would be upset. She said she would probably feel embarrassed. During an interview on 10/23/24 at 3:00 p.m., the Treatment Nurse said this had happened to her dad she would be hell mad. She said the video was a dignity issue and abusive to the resident. During an interview on 10/23/24 at 3:18 p.m., CNA D if someone took a video of her or a family member naked, she would be livid. She said if it were her, she would feel humiliated. During an interview on 10/23/24 at 3:23 p.m., the Activity Director said if someone videoed her naked and shared it with others, she would be ashamed, mad, embarrassed and just pissed off. During an interview on 10/23/24 at 3:26 p.m., ADON F said she was a floor nurse when the video was taken. She said she never even heard about the video until there were in-services. She said if this happened to her or her family it would be upsetting. She said it was a modesty and dignity issue. She said it was a lack of respect. During an interview on 10/23/24 at 3:31 p.m., PTA L said if it happened to her, she would not like it at all. She said she would be extremely embarrassed and angry. She said she did take seriously that these are people's lives and they had feelings. During an interview on 10/23/24 at 3:46 p.m., LVN C said if someone took a video of her naked and shared it with other people, she would feel embarrassed and violated. During an interview on 10/23/24 at 4:02 p.m., LVN E said if this happened to family it would made him highly upset. He said he would be furious if it happened to him. He said it would be a total invasion of privacy. During an interview on 10/23/24 at 4:12 p.m., the Staffing Coordinator said if someone took a video of her naked and shared it with other people, she would feel embarrassed. During an interview on 10/23/24 at 4:21 p.m., the Clinical Resource Nurse said she learned of the video during one of her weekly visits. She said it was probably on 08/22/24 or 08/23/24. She said she was told there was a nurse that had taken an inappropriate video of a resident not fully dressed and that it was sent to a staff member that was not on duty that day. She said she interviewed RN A. She said RN A was off that day and she was told she had to come to the facility to be interviewed. She said RN A admitted to taking the video. She said during interview RN A said, there was no reason for taking the video. She RN A said during that interview she had shown the video to no one. The Clinical Resource Nurse said she never saw the video. She said RN A told her the video was no longer on her phone, and she had deleted the video. She said every staff member was in-serviced. She said there were some one-on-one in-services. She said these were with the people that were disciplined. She said RN A was suspended that day. She said RN A's license were referred to the state. She said if this happened to her, she would be humiliated. She said it would be humiliating regardless of her age. She said she was angry and very emotional about what happened. She said it was just disgusting. She said she had assisted with safe surveys and with Resident #1 and he had no concerns. She said she did know Administrator G had interviewed the resident. She said Administrator G told her the resident did not recall the incident. She said Administrator G was asked to resign or he would be terminated. During an interview on 10/23/24 at 4:45 p.m., the DON said if someone took a video of her naked and shared it with other people, she would feel absolutely disgusted, violated, and awful. During an interview on 10/22/24 at 4:46 p.m., Administrator M said he was not the administrator when the incident happened or when it was first reported. He said his first day was on 10/2/24. He said he would consider the video abuse. He said abuse sums it up. He said if it happened to him, he would feel terrified and abused. He said it was never something you wanted to see in your own facility. Record review of a Counseling/Disciplinary Notice dated 08/22/24 indicated an allegation of abuse was identified and RN A was suspended pending investigation. RN A was notified at 5:08 p.m. by the DON. Record review of a Counseling/Disciplinary Notice dated 08/ [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure the right to be free from abuse was provided for 1 of 11 residents reviewed for abuse. (Resident #1) The facility failed protect Resident #1 from abuse when RN A recorded him on 07/26/24 with her personal cellphone while undressed from the waist down. RN A was laughing. RN A showed and sent the video to other staff. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/26/24 and ended on 08/30/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for emotional and mental abuse. Findings included: Record review of a face sheet dated 10/22/24 revealed Resident #1 was an [AGE] year-old male and admitted on [DATE] with diagnoses including dementia, depression, and anxiety. Record review of a quarterly MDS dated [DATE] revealed Resident #1 was understood and usually understood others. The MDS revealed a BIMS score of 7, indicating severe cognitive impairment. The MDS indicated Resident #1 required supervision with most ADLs. Record review of Resident #1's physician order dated 08/23/24 indicated a verbal order was obtained to monitor for emotional distress every shift for 3 days. Record review of a care plan last revised on 10/12/24 revealed Resident #1 was at risk for impaired thought processes related to a history of dementia. Resident #1 needed assistance with all decision making. Resident #1 had an ADL self-care performance deficit related to decreased mobility and intermittent confusion. The care plan indicated Resident #1 had potential for a behavior problem as evidenced by inappropriate sexual behaviors. There was an intervention to provide privacy and encourage resident to remain clothed per family request. Record review of a Grievance Resolution Form dated 08/23/24 indicated Resident #1 was involved in a video without his knowledge. The report indicated the compliance department was involved and notified administration. Record review of a Progress Note dated 08/23/24 indicated, SW (Social Worker) visited with resident (Resident #1) this afternoon .SW noticed no change in his mood or behavior after he was notified of the incident. He continues to show confusion, per his usual state. He states I am OK. I am not going to let this effect my life. He is agreeable to speaking with (psych services). SW has sent in a referral for evaluation and spoke with .counselor, re: the incident. SW will continue to monitor resident and will assist further as needed. The note was signed by the Social Worker. Record review of Nurse's notes for Resident #1 dated 08/23/24 - 08/28/24 indicated Resident #1 was monitored for mood and distress. The notes did not indicate Resident #1 had a change in mood or emotional distress. Record review of an Investigation Summary and Timeline report dated 08/30/24 indicated the DON was notified of the allegation of abuse on 08/22/24 at approximately 5:00 p.m. related to the conduct of RN A. The allegation suggested that the nurse had taken an unauthorized video of a resident. RN A was immediately suspended at the time it was reported, pending investigation. During the interview process, it was confirmed that RN A had taken a video of a resident while in his room The resident was not wearing pants and his genitals were visible. The Investigation Summary and Timeline indicated that Resident #1 had been interviewed by Administrator G and had knowledge of the video at the time of the interview. The Investigation Summary and Timeline report indicated RN A was terminated in person on 08/26/24. The report indicated the police were notified and the RP requested to press charges against RN A. Record review of a Provider Investigation Report dated 08/23/24 indicated that on an unknown date RN A took an unauthorized video of Resident #1. The investigation findings were confirmed. Record review of an interview of RN A dated 08/23/24 at 9:30 a.m. indicated she had taken a video of Resident #1. She stated Resident #1 had been in his room with his roommate. She said it had been reported to her by someone in therapy that they smelled smoke in the residents' room. She said she went to the room and Resident #1 was leaning over his roommate and his genitals were rubbing on the roommate. She stated the video showed Resident #1's backside, naked from the waist down. She said she showed the video to LVN C. She said the purpose of filming the video was to show LVN C the residents behavior. She stated, .I shouldn't have done that. I should have verbally told the nurse or done a progress notes. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by RN A. On 10/22/24 at 11:30 a.m., an attempt was made to reach RN A by telephone. There was no answer. A detailed message requesting a return call was left on voicemail. Record review of an interview of LVN C dated 08/23/24 at 10:10 a.m. indicated that she knew about and had seen the video. She said she had seen the video. She said it was of Resident #1 walking over to his roommate. She said Resident #1 only had a shirt on. She said she just saw the back of Resident #1. She said she saw his buttocks. She said he was bending over to do something, and she could see his genitals hanging down. She said RN A had shown her from her phone. She stated RN A said, Oh my God, look what (Resident #1) did. She said RN A thought it was funny. She said she did not report the video. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by LVN C. Record review of an interview of the Transport Aide dated 08/23/24 at 10:20 a.m. indicated the Transport Aide was aware of and had seen the video. She said the video was shown to her by RN A. She said the video was of Resident #1 walking with a shirt on. She said she could see Resident #1's genitals. The interview indicated that the Transport Aide asked RN A why she had the video and RN A said something to her about when he was younger, he probably had big balls. The Transport Aide said she had seen the video weeks ago. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by the Transport Aide. During an interview on 10/22/24 at 3:34 p.m., the Transport Aide said she walked in one morning. She said RN A said to come see the video and said, it's really funny. She said she did not understand why RN A would have even filmed the video. She said she watched the video on RN A's phone, and it was never sent to her. She said she thought the video was shown to her in July 2024. She said the video was inappropriate. She said on the video she saw Resident #1 over by the air conditioner. She said RN A said, Look at his balls going back in forth, I bet when he was younger, he was bigger. Record review of an interview of CNA D dated 08/23/24 at 10:20 a.m. indicated CNA D was aware of the video and that she had seen the video. She said it was both shown to her and sent to her via text by RN A. She stated that on the video Resident #1 was standing by his roommate with no pants or underwear on, just a shirt. Resident #1 leaned over to help his roommate and she saw his buttocks, penis, and scrotum. She said it had been less than a month since she had seen the video. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by CNA D. Record review of an interview of LVN E dated 08/23/24 at 10:20 a.m. indicated LVN E had heard about the video but had not seen the video. He stated it had been about a month since he had heard about the video. He said he heard there was a video of Resident #1's genitalia. He said RN A had told him about the video. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by LVN E. Record review of an interview of the Staffing Coordinator dated 08/23/24 at 11:05 a.m. indicated the Staffing Coordinator became aware of the video on 08/22/24. The Staffing Coordinator stated RN A came to the office and stated that compliance had called her about a video she had taken of one of the residents and she was scared and didn't know what to do. The Staffing Coordinator indicated she had not seen the video and had only heard gossip about the video. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by the Staffing Coordinator. During an interview on 10/22/24 at 11:42 a.m., the Staffing Coordinator said she was in the hallway on a day in August 2024. She did not remember the date. She said RN A pulled her into the office and said compliance had reached out to her and she did not know what to do. The Staffing Coordinator said RN A was scared. The Staffing Coordinator said RN A said, I think they are calling me about the video. The Staffing Coordinator said she had heard rumors about the video but was not sure if those rumors were true. She said she has never seen the video. She said she heard there was a video out of a resident that they had at the time. She said she did not know any details. She said RN A did not tell her what was on the video or show it to her. She said she reported the incident to the DON after RN A had come into her office. During an interview on 10/22/24 at 11:42 a.m., the Staffing Coordinator said she was in the hallway on a day in August 2024. She did not remember the date. She said RN A pulled her into the office and said compliance had reached out to her and she did not know what to do. The Staffing Coordinator said RN A was scared. The Staffing Coordinator said RN A said, I think they are calling me about the video. The Staffing Coordinator said she had heard rumors about the video but was not sure if those rumors were true. She said she has never seen the video. She said she heard there was a video out of a resident that they had at the time. She said she did not know any details. She said RN A did not tell her what was on the video or show it to her. She said she reported the incident to the DON after RN A had come into her office. Record review of a telephone interview of the Treatment Nurse dated 08/23/24 at 11:15 a.m. indicated the Treatment Nurse was aware of and had seen the video. She said it was shown to her right before she went on maternity leave. She said in the video she could see Resident #1's behind and his scrotum between his legs. She said RN A had shown her the video. She said it was on RN A's phone. The Treatment Nurse said she had mentioned the video to Administrator G and ADON H. She said she may have reported it the next day but could not remember. She stated that RN A thought the video was funny and was showing staff. She said she told RN A that the video was inappropriate, and she should not be videoing the residents. The interview was conducted and signed by the DON and the Clinical Resource Nurse. During an interview on 10/22/2024 at 1:06 p.m., the Treatment Nurse said she went on leave in August 2024. She said it would have been the middle of August 2024. She said RN A did show her the video. She said RN A did not send her the video. She said RN A stopped her in the hall and said, Hey look at this. She said you could see Resident #1 and his roommate messing with the air conditioner. She said Resident #1 only had a shirt on. She said you could see his scrotum. She said the video was from behind and she was not sure if you could see the resident's penis. She said it did not appear Resident #1 was aware he was being videoed. She said RN A was laughing about the video. She said she told RN A it was inappropriate, and RN A said, I just thought it was funny. She said she did report it immediately to the previous ADON H that and told Administrator G the same day. She said she told Administrator G on 07/30/24 or 07/31/24. She said Administrator G told her he would address it at the next all staff meeting. Record review of a police Incident Report, dated 08/23/24 indicated Administrator G was the reportee. The report indicated the offense was solicitation to commit - invasive visual recording in bathroom/changing room. The report indicated RN A was the offender. The report indicated the officer spoke with Administrator G and the DON. The report indicated the DON explained that RN A recorded a patient in secret. The report indicated Resident #1 liked to walk around in the nude and RN A had secretly recorded Resident #1 and sent the video through text to RN B and made jokes about Resident #1. RN A showed her co-workers the video while making fun of Resident #1. The officer asked RN B if she still had the video and was told that she had deleted it. The report indicated on 08/27/24 It was concluded by (the facility) that (RN A) had acted inappropriately by recording (Resident #1) and was subsequently terminated for that reason. According to the interviews, (RN A) was distributing the video to other employees and making comments like, When he was younger, he probably had big balls and Look what you're missing out on. RN A herself was interviewed and stated that her reasoning for recording (Resident #1) was to provide his nurse with information on his behavior. During an interview on 10/22/24 at 9:28 a.m. a family member of Resident #1 said the incident of RN A videoing Resident #1 had been reported to the police. He said the investigating officer was Officer J. He said RN A took a video of Resident #1 and shared the video with her co-workers. The family member said they had not personally seen the video. The family said said Officer J had seen the video. He said Officer J had interviewed some of the facility staff at the police department and had taken several phones. The family member said one of the phones had produced the video. The family member said they did not know which one had. The family member said the facility was aware of the incident in July 2024. The family member said they were not notified of the video until the end of August 2024. The family member said Resident #1 had no memory of the incident. The family member said Resident #1 cannot even remember what he had for breakfast. During an interview and observation on 10/22/24 at 1:30 p.m., Officer J said nursing home staff did not report the video to the police department until a month after it was recorded. He said then the following week, Resident #1's family had reported the video to the police department. He said the first report was made on 8/23/2024. He said review of the video indicated a create date of 7/26/24. He said the police department still had custody of CNA D's and RN B's cell phones. He said they each gave consent for their phones to be searched. He said the video was eventually found on RN B's cellphone. He said on some of the phones there were text messages from the staff members and RN A discussing what Resident #1 might have looked like when he was younger. The video was observed in Officer J's office. The video showed Resident #1 from behind. Resident #1's roommate was sitting in a chair. Each resident had their backs to the camera. Resident #1 had on a polo type shirt. He was naked from the waist down. His buttocks and testicles were visible. At one point in the video, Resident #1 walked over to his roommate and bent over as if to help him with something. When the resident bent over it further exposed his testicles. In the background, there was heard a female voice laughing off and on throughout the video. At one point the female voice said, What is he doing? followed by more laughter. During an observation on 10/22/24 at 2:00 p.m., a video of RN B being interviewed by Officer J revealed RN B stated RN A had sent the video to a few people. RN B said the video was, inappropriate to say the least. RN B said RN A sent the video to her between 07/21/24 to 07/28/24. RN B said she had deleted the video from her phone after she found out that compliance had called RN A. RN B said she had deleted text messages from her phone also. During an interview on 10/23/24 at 8:25 a.m., RN B said she went on vacation for a whole week. She said she then tested positive for Covid and was off another week. She said texted RN A to ask what she had missed at work. She said RN A said, Hey I'm about to send you a video. She said she watched most of the video but not all of it. She said this was normal behavior for Resident #1 and she had seen this behavior daily. She said she felt the video was inappropriate. She said she thought the video was meant to be humorous. She said she thought she typed back, LOL. She said after that she did not think anything else about the video. She said she was sick, and she really did not give it much thought. She said RN A texted her and told her she had sent the video to several other people. She said she did not know the date the video was sent to her, but it was towards the end of July 2024 because she was home sick. She said Resident #1 had a shirt on and nothing below. She said he was walking away from the camera. She said that was as far as she watched. She said she could see his buttocks. She said she did not have her glasses on and did not see his testicles. She said around 8/28/24 she did have a meeting with Compliance. She said she had already deleted the video from her phone. She said now the police had her phone. She said it was sent to forensics and they found the video on the phone. During an observation on 10/22/24 at 2:10 p.m., a video of CNA D was being interviewed by Officer J. CNA D said she was shown the video in the hallway right after RN A had come out of Resident #1's room. CNA D said that at the nurse's station RN A was showing the video to LVN C, LVN E, and herself. During an interview on 10/22/24 at 4:20 p.m., CNA D said RN A sent the video to her the day she recorded the video. She said this date was 7/27/24 on her birthday. She said the resident's roommate was in his wheelchair over by the air conditioner. She said Resident #1 was standing over him with a polo type shirt on and was naked from the waist down. She said she could see his buttocks, testicles, and his penis. She said RN A did not tell her why she took the video. She said she could not remember the context of her conversation with RN A. She said she could not remember if she saw all of the video, but she did feel it was inappropriate. She said she did not report the video to anyone. She said she was not aware of anyone else seeing the video. She said RN A never showed the video to LVN C, LVN E, and herself at the nurse's station. During an interview on 10/22/24 at 2:38 p.m., LVN C said RN A just showed her the video to show her what he was doing. She said the video was just the back of Resident #1 walking over to his roommate with just a shirt on. She said you could not see his face. She said you could see his testicles from behind. She said the video was never sent to her. She said she was at her medication cart when RN A showed her the video. She said LVN E and CNA D were at the facility but were not present when she watched the video. She said the resident's behavior was not a shock to her because he did stuff like that all the time. She said the video was inappropriate and was not necessary. She said RN A was laughing and said, I can't believe this, look at him. She said she was not sure of the date the video was taken. She said she felt RN A showed it to her immediately after it was recorded. She said Resident #1 had dementia and would not remember the incident. She said one time he had even walked down the hall with only a shirt on. During an interview on 10/22/24 at 3:24 p.m., PTA L said she was aware RN A took a video of Resident #1. She said RN A showed her the video on her phone. She said she saw Resident #1 in his room naked from the waist down. She said he had only a shirt on. She said he was walking around the room. She said as soon as she saw it, she quit watching the video. She said she did not know if it was the day, RN A took the video. She said when RN A showed her the video she was laughing. She thought it was funny. She said Resident #1 was not aware the incident happened. During an interview on 10/22/24 at 3:56 p.m., Administrator G said what occurred was HR K informed him that a video was going around. He said that was either 7/31/2024 or 8/2/2024. He said he thought it was in August 2024. He said he could not remember if she gave him details of the video. He said the allegation did not hit his abuse and neglect radar. He said about two weeks later the DON was informed of the video and communicated the details the video to him and it was reported. He said RN A was suspended immediately and never brought back from suspension. He said he did send a text to the Treatment Nurse on 08/02/24. He said he did say the video was inappropriate. He said he just did not realize how bad the video was or the response would have been completely different. He said he had never seen the video. He said he left the facility sometime in August 2024. He said he was given the option to resign. During an interview 10/22/24 at 4:12 p.m., the Social Worker said she was not even aware of the video until compliance got involved. She said she usually did a checkup with residents after any incident. She said she did safe surveys and there were no concerns. She said she did talk to Resident #1. She said Administrator G had just come out of his room, so the incident was fresh on Resident #1's mind. She said he did not seem upset. She said he did say, I just don't know why someone would do something like that. I'm not going to let it affect me. She said she did get an order for psychology services to check on him. During an interview on 10/23/24 at 9:14 a.m., HR K said she found out about the video on 8/2/24. She said ADON H told her about the video. She said, and still nothing was done. She said she never saw the video. She said she was told by multiple people it did exist and what it consisted of. During an interview on 10/23/24 at 9:31 a.m., the DON said she first became aware of the video approximately 2 days before she reported the incident to the state. She said HR K told her but did not tell her any details about the video. She said prior to 8/21/24 she had not even heard of the video. She said she was on vacation 7/30/24 - 8/5/24. She said the video was not reported to her during that time. She said on 8/22/24 she became of aware of the content of the video. She said she was told by the Staffing Coordinator. She said the Staffing Coordinator told her there was a video of Resident #1 with his genitals exposed and that RN A had taken the video. She said she suspended RN A immediately. She said she began the investigation herself on 8/23/24. She said her investigation concluded that RN A had taken the video of Resident #1 and had shown multiple co-workers. She said RN A was terminated on 08/26/24. She said she had not seen the video. She said all staff that had knowledge of or saw the video was given final written warnings for failure to report. She said once she heard the content of the video, she felt it was abuse. She said she felt it should have been reported and investigated right from the very beginning. She said she did talk to Resident #1 about the video. She said he did not remember the incident unless it was brought up by staff. She said she did feel like this was a dignity issue. She said he had been the mayor at one time. She said he was a photographer. She said he could not help his behavior. During an interview on 10/23/24 at 2:21 p.m., a family member of Resident #1 said in the condition of dementia or Alzheimer's they would not know if this had happened to them. The family member said if they did know, they would feel it was demeaning or demoralizing and against all privacy. They said they thought the whole thing horrible. They said Resident #1 had been a very private but public person. The family member said Resident #1 was the mayor at one time. The family member said Resident #1 never discussed the birds and bees with them because he was a private person. The family member said Resident #1 would not have liked this at all. During an interview on 10/23/24 at 4:21 p.m., the Clinical Resource Nurse said she learned of the video during one of her weekly visits. She said it was probably on 08/22/24 or 08/23/24. She said she was told there was a nurse that had taken an inappropriate video of a resident not fully dressed and that it was sent to a staff member that was not on duty that day. She said she interviewed RN A. She said RN A was off that day and she was told she had to come to the facility to be interviewed. She said RN A admitted to taking the video. She said during interview RN A said, there was no reason for taking the video. She RN A said during that interview she had shown the video to no one. The Clinical Resource Nurse said she never saw the video. She said RN A told her the video was no longer on her phone, and she had deleted the video. She said every staff member was in-serviced. She said there were some one-on-one in-services. She said these were with the people that were disciplined. She said RN A was suspended that day. She said RN A's license were referred to the state. She said if this happened to her, she would be humiliated. She said it would be humiliating regardless of her age. She said she was angry and very emotional about what happened. She said it was just disgusting. She said she had assisted with safe surveys and with Resident #1 and he had no concerns. She said she did know Administrator G had interviewed the resident. She said Administrator G told her the resident did not recall the incident. She said Administrator G was asked to resign or he would be terminated. Record review of a Counseling/Disciplinary Notice dated 08/22/24 indicated an allegation of abuse was identified and RN A was suspended pending investigation. RN A was notified at 5:08 p.m. by the DON. Record review of a Counseling/Disciplinary Notice dated 08/26/24 indicated RN A was discharged from employment and her last day worked was 08/20/24. The notice indicated, It was determined that the nurse, (RN A), was responsible for the recording and distributing inappropriate video of a resident to multiple staff members. This is against our Abuse Policy as it classifies as Mental Abuse. Staff member is to be terminated for violation of Abuse Policy. The notice was signed by Administrator G and RN A on 08/27/24. Record review of a Termination Form dated 08/27/24 indicated RN A was terminated with a termination date of 08/27/24 for gross misconduct. The Termination Form was signed by the DON. Record review of an undated Employer Report Form to the Texas Board of Nursing Regarding Violations of the Nursing Practice Act, Other Statutes, and Board Rules indicated, It was reported that (RN A) had taken inappropriate video of the resident (Resident #1) and was distributing the video to her co-workers via multimedia message. Upon investigation, it was identified that (RN A) had videoed the resident nude from the waist down while he ambulated in his room and shown multiple coworkers on her phone, as well as sent it via text message to at least 2 coworkers. Through investigation it was determined that there was no reason medical indication for the video to be taken. It has been determined through this investigation that the nurse mentally abused the resident by taking and distributing this video. CMS defines mental abuse as, abuse that is facilitated or caused by nursing home staff taking or using photographs or recording in any manner that would demean or humiliate a resident (Ref. S&C16-33-NH). Employment has been terminated at this facility due to this crime. Record review of a Social Media facility policy dated December 2020 indicated, .An employee's use of social media, both during work time and non-work time, may subject the employee to discipline if their conduct violates company policies or law . Record review of an Abuse: Prevention of and Prohibition Against facility policy dated 11/2017 indicated, .It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Facility staff are prohibited from taking, keeping, using or distributing photographs or video recordings of Facility residents in any manner that would demean or humiliate a resident, regardless of whether the resident provided consent and regardless of the resident's cognitive status. This includes using any type of equipment (e.g., cameras, smart phones, or other electronic devices) to take, keep, or distribute inappropriate photographs or recordings on social media. The Facility will provide oversight and monitoring to ensure that staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse, neglect, misappropriation of resident property, and exploitation .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Mental Abuse includes, but is not limited to humiliation . The facility had corrected the noncompliance on 08/30/24 by the following: - Termination of RN A who was responsible for the abuse - Resignation of Administrator G who was responsible for not reporting or investigating the abuse. - Final Written Warnings for the failure to report alleged abuse to supervisor or abuse coordinator dated 08/23/24 were given to Transport Aide, the Staffing Coordinator, CNA D, LVN E, LVN C, and RN B. PTA L was given a Final Written Warning for the failure to report alleged abuse to supervisor or abuse coordinator on 08/29/24. - Safe surveys of all the residents in the facility initially and weekly for 90 Days. (on-going at the time of exit) - 100% staff in-service on Code of Conduct, Photographing or Videoing a resident (Abuse and Neglect), Abuse: Prevention of and Prohibition Against, and Abuse Coordinator - 100% staff knowledge checks on Abuse and Neglect Prevention and Reporting - 100% staff Abuse Prevention & Reporting Skills Check - 100% staff on-line training on Knowing the Resident Rights, HIPPA Refresher (TO), Abuse Neglect and Exploitation, Obligation to Report Abuse - Psychological Services were provided to Resident #1 beginning 8/27/24 Record review of an Ad Hoc Quality Assurance (QA) Meeting Sign-in Sheet dated 08/23/24 indicated the facility had an QA meeting addressing the incident. The QA Meeting Sign-in Sheet indicated the DON, ADON, Medical Director, Marketing Representative, Admissions Coordinator, LVN N, Maintenance Director, Activity Director MDS Nurse, Medical Records staff member, Resource Therapist, the Treatment Nurse, and Operations Manager. Record review and interview of the sampled residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, and Resident #11) revealed they had not been abused or witnessed any abuse of other residents. They each said to their knowledge they had not been photographed or videoed by any staff members. All staff interviewed (RN B, LVN C, CNA D, LVN E, ADON F, HR K, PTA L, LVN O, the Staffing Coordinator, the Transport Aide, the Treatment Nurse, the Social Worker, CNA P, the Activity Director, the Dietary Manager, the Speech Therapist, Laundry Aide Q, CNA R) on 10/22/24 and 10/23/24 verbalized they had been in-serviced on Code of Conduct, Abuse/Neglect policy, Facility Staff were prohibited from taking, keeping, using or distributing photographs or video recording of facility residents, Abuse: Prevention of and Prohibition Against. Each staff member said they had taken online training of Knowing the Resident Rights, HIPPA Refresher (TO), Abuse Neglect and Exploitation, Obligation to Report Abuse. Each staff member was able to verbalize the different types of abuse. Each said they would report any abuse immediately to the abuse coordinator and during the time there was not an administrator the Abuse Coordinator was the DON. Each staff m [TRUNCATED]

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation, or mistreatment of residents for 1 of 11 residents (Resident #1) reviewed for abuse and neglect. The facility failed to prevent Resident #1 from being abused when on 07/26/2024 RN A entered his room and filmed him with her cellphone. Resident #1 was naked from the waist down. RN A shared the video with other staff. The facility failed to protect Resident #1 from potential further abuse after the allegation. RN A was allowed to work from the date of the incident until she was suspended on 08/22/24. The facility staff (RN B, LVN C, CNA D, LVN E, the Staffing Coordinator, the Transport Aide, PTA L) failed to report abuse immediately to the Abuse Coordinator after they had viewed or became aware of the video. Facility Administrator G failed to investigate and to report an allegation of abuse to the state agency after he became aware of the video on 07/31/24. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/26/24 and ended on 08/30/24. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for continued abuse and neglect due to inappropriate interventions and failure to report the allegations of abuse timely. Findings included: Record review of an Abuse: Prevention of and Prohibition Against facility policy dated 11/2017 indicated, .It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Facility staff are prohibited from taking, keeping, using or distributing photographs or video recordings of Facility residents in any manner that would demean or humiliate a resident, regardless of whether the resident provided consent and regardless of the resident's cognitive status. This includes using any type of equipment (e.g., cameras, smart phones, or other electronic devices) to take, keep, or distribute inappropriate photographs or recordings on social media. The Facility will provide oversight and monitoring to ensure that staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse, neglect, misappropriation of resident property, and exploitation .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Mental Abuse includes, but is not limited to humiliation .All personnel, residents, visitor, etc. are encouraged to report incidents and grievance without the fear of retribution. The Facility will act to protect and prevent abuse and neglect from occurring with the Facility by .Supervising staff to identify and correct any inappropriate or unprofessional behavior .Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur .Facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or the Facility administrator immediately .This includes taking, keeping, using or distributing photographs or video recordings of Facility resident in any manner that would demean or humiliate a resident .with any type of device .All identified events are reported to the Administrator immediately .After receiving the allegation, and during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm .All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigate by the Administrator or his/her designee .Upon receiving a report or allegation of a potential violation of this policy involving the taking, keeping, using, or distributing photos or video recordings, the Administrator or his or her designee will analyze the allegations and determine whether the conduct at issue implicated resident privacy or security as protected by the Health Insurance Portability and Accountability Act (HIPPA) .The investigation will include .an interview with the person(s) reporting the incident .an interview with the resident(s) .Interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate .a review of the resident's medical record .An interview with staff members (on all shifts) who may have information regarding the alleged incident .Interviews with other residents to whom the accused employee provides care or services or who may have information regarding the alleged incident .an interview with staff members (on all shifts) having contact with the accused employee and a review of all circumstance surrounding the incident .To the extent there is evidence that could be sued in a criminal investigation, staff will immediately notify the Administrator or his/her designee .The investigation, and the results of the investigation, will be documented .If an allegation of abuse .is reported, discovered or suspected, the Facility will take the following steps to protect all residents .respond immediately to protect the alleged victim and the integrity of the investigation .examine the alleged victim for any sign of injury, including a physical examination and psychosocial assessment .Increase supervision of the alleged victim and residents .make room or staffing changes .provide emotional support and counseling to the resident during and after the investigation .immediately remove the employee from the care of any resident .Suspend the employee during the pendency of the investigation . All allegations of abuse .should be reported immediately to the Administrator .Allegations of abuse .will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations .At the conclusion of the investigation, the Facility will take action, as necessary, in light of the information gathered which may include but is not limited to . Record review of a face sheet dated 10/22/24 revealed Resident #1 was an [AGE] year-old male and admitted on [DATE] with diagnoses including dementia, depression, and anxiety. Record review of a quarterly MDS dated [DATE] revealed Resident #1 was understood and usually understood others. The MDS revealed a BIMS score of 7, indicating severe cognitive impairment. The MDS indicated Resident #1 required supervision with most ADLs. Record review of Resident #1's physician's orders indicated on dated 08/23/24 indicated a verbal order was obtained to monitor for emotional distress every shift for 3 days. Record review of a care plan last revised on 10/12/24 revealed Resident #1 was at risk for impaired thought processes related to a history of dementia. Resident #1 needed assistance with all decision making. Resident #1 had an ADL self-care performance deficit related to decreased mobility and intermittent confusion. The care plan indicated Resident #1 had potential for a behavior problem as evidenced by inappropriate sexual behaviors. There was an intervention to provide privacy and encourage resident to remain clothed per family request. Record review of text messages dated 08/02/24 at 6:14 p.m., indicated texts between HR K and Administrator G. The texts indicated HR K wrote, .And ANOTHER note, I don't know who, how or where it originated from but there has been a video taken of (Resident #1) with no pants on and making its way around the building. Administrator G responded, Oh no! If you're still there, will you mention to one or two of the staff at the nurse's station that any videos taken of residents against their will can give family members a foot hold to sue whoever has the video. HR K responded, I left unfortunately but I was told over the phone, not in person at the facility or I would have said just that and how it's not funny. Administrator G responded, Mmm, ok. I'll mention it to (the Treatment Nurse). Record review of a text message dated 08/02/24 at 6:38 p.m. to the Treatment Nurse from Administrator G indicated, Hey, I just got word that there's an inappropriate video of (Resident #1) going around the facility. Will you mention to the staff that any videos taken of residents against their will can give family members a foot hold to sue whoever has the video. It has happened to our sister facility . Record review of a Grievance Resolution Form dated 08/23/24 indicated Resident #1 was involved in a video without his knowledge. The report indicated the compliance department was involved and notified administration. Record review of a Progress Note dated 08/23/24 indicated, SW (Social Worker) visited with resident (Resident #1) this afternoon .SW noticed no change in his mood or behavior after he was notified of the incident. He continues to show confusion, per his usual state. He states I am OK. I am not going to let this effect my life. He is agreeable to speaking with (psych services). SW has sent in a referral for evaluation and spoke with .counselor, re: the incident. SW will continue to monitor resident and will assist further as needed. The note was signed by the Social Worker. Record review of Nurse's notes for Resident #1 dated 08/23/24 - 08/28/24 indicated Resident #1 was monitored for mood and distress. The notes did not indicate Resident #1 had a change in mood or emotional distress. Record review of an Investigation Summary and Timeline report dated 08/30/24 indicated the DON was notified of the allegation of abuse on 08/22/24 at approximately 5:00 p.m. related to the conduct of RN A. The allegation suggested that the nurse had taken an unauthorized video of a resident. RN A was immediately suspended at the time it was reported, pending investigation. During the interview process, it was confirmed that RN A had taken a video of a resident while in his room The resident was not wearing pants and his genitals were visible. The Investigation Summary and Timeline indicated that Resident #1 had been interviewed by Administrator G and had knowledge of the video at the time of the interview. The Investigation Summary and Timeline report indicated RN A was terminated in person on 08/26/24. The report indicated the police were notified and the RP requested to press charges against RN A. Record review of a Provider Investigation Report dated 08/23/24 indicated that on an unknown date RN A took an unauthorized video of Resident #1. The investigation findings were confirmed. Record review of an interview of RN A dated 08/23/24 at 9:30 a.m. indicated she had taken a video of Resident #1. She stated Resident #1 had been in his room with his roommate. She said it had been reported to her by someone in therapy that they smelled smoke in the residents' room. She said she went to the room and Resident #1 was leaning over his roommate and his genitals were rubbing on the roommate. She stated the video showed Resident #1's backside, naked from the waist down. She said she showed the video to LVN C. She said the purpose of filming the video was to show LVN C the residents behavior. She stated, .I shouldn't have done that. I should have verbally told the nurse or done a progress notes. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by RN A. On 10/22/24 at 11:30 a.m., an attempt was made to reach RN A by telephone. There was no answer. A detailed message requesting a return call was left on voicemail. Record review of an interview of LVN C dated 08/23/24 at 10:10 a.m. indicated that she knew about and had seen the video. She said she had seen the video. She said it was of Resident #1 walking over to his roommate. She said Resident #1 only had a shirt on. She said she just saw the back of Resident #1. She said she saw his buttocks. She said he was bending over to do something, and she could see his genitals hanging down. She said RN A had shown her from her phone. She stated RN A said, Oh my God, look what (Resident #1) did. She said RN A thought it was funny. She said she did not report the video. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by LVN C. Record review of an interview of the Transport Aide dated 08/23/24 at 10:20 a.m. indicated the Transport Aide was aware of and had seen the video. She said the video was shown to her by RN A. She said the video was of Resident #1 walking with a shirt on. She said she could see Resident #1's genitals. The interview indicated that the Transport Aide asked RN A why she had the video and RN A said something to her about when he was younger, he probably had big balls. The Transport Aide said she had seen the video weeks ago. The interview indicated the Transport Aide did not report the video to anyone and when asked why she said, I know I should have. I don't know why I didn't. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by the Transport Aide. During an interview on 10/22/24 at 3:34 p.m., the Transport Aide said she walked in one morning. She said RN A said to come see the video and said, it's really funny. She said she did not understand why RN A would have even filmed the video. She said she watched the video on RN A's phone, and it was never sent to her. She said she thought the video was shown to her in July 2024. She said the video was inappropriate. She said on the video she saw Resident #1 over by the air conditioner. She said RN A said, Look at his balls going back in forth, I bet when he was younger, he was bigger. Record review of an interview of CNA D dated 08/23/24 at 10:20 a.m. indicated CNA D was aware of the video and that she had seen the video. She said it was both shown to her and sent to her via text by RN A. She stated that on the video Resident #1 was standing by his roommate with no pants or underwear on, just a shirt. Resident #1 leaned over to help his roommate and she saw his buttocks, penis, and scrotum. She said it had been less than a month since she had seen the video. She said she did not report the video to anyone. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by CNA D. Record review of an interview of LVN E dated 08/23/24 at 10:20 a.m. indicated LVN E had heard about the video but had not seen the video. He stated it had been about a month since he had heard about the video. He said he heard there was a video of Resident #1's genitalia. He said RN A had told him about the video. He said he thought he should have reported the video but did not report the video. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by LVN E. Record review of an interview of the Staffing Coordinator dated 08/23/24 at 11:05 a.m. indicated the Staffing Coordinator became aware of the video on 08/22/24. The Staffing Coordinator stated RN A came to the office and stated that compliance had called her about a video she had taken of one of the residents and she was scared and didn't know what to do. The Staffing Coordinator indicated she had not seen the video and had only heard gossip about the video. She said the staff that were gossiping did explain what was in the video. She said she did not report what was in the video because it was just gossip. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by the Staffing Coordinator. During an interview on 10/22/24 at 11:42 a.m., the Staffing Coordinator said she was in the hallway on a day in August 2024. She did not remember the date. She said RN A pulled her into the office and said compliance had reached out to her and she did not know what to do. The Staffing Coordinator said RN A was scared. The Staffing Coordinator said RN A said, I think they are calling me about the video. The Staffing Coordinator said she had heard rumors about the video but was not sure if those rumors were true. She said she has never seen the video. She said she heard there was a video out of a resident that they had at the time. She said she did not know any details. She said RN A did not tell her what was on the video or show it to her. She said she reported the incident to the DON after RN A had come into her office. Record review of a telephone interview of the Treatment Nurse dated 08/23/24 at 11:15 a.m. indicated the Treatment Nurse was aware of and had seen the video. She said it was shown to her right before she went on maternity leave. She said in the video she could see Resident #1's behind and his scrotum between his legs. She said RN A had shown her the video. She said it was on RN A's phone. The Treatment Nurse said she had mentioned the video to Administrator G and ADON H. She said she may have reported it the next day but could not remember. She stated that RN A thought the video was funny and was showing staff. She said she told RN A that the video was inappropriate, and she should not be videoing the residents. The interview was conducted and signed by the DON and the Clinical Resource Nurse. During an interview on 10/22/2024 at 1:06 p.m., the Treatment Nurse said she went on leave in August 2024 . She said it would have been the middle of August 2024. She said RN A did show her the video. She said RN A did not send her the video. She said RN A stopped her in the hall and said, Hey look at this. She said you could see Resident #1 and his roommate messing with the air conditioner. She said Resident #1 only had a shirt on. She said you could see his scrotum. She said the video was from behind and she was not sure if you could see the resident's penis. She said it did not appear Resident #1 was aware he was being videoed. She said RN A was laughing about the video. She said she told RN A it was inappropriate, and RN A said, I just thought it was funny. She said she did report it immediately to the previous ADON H that and told Administrator G the same day. She said she told Administrator G on 07/30/24 or 07/31/24. She said Administrator G told her he would address it at the next all staff meeting. Record review of a police Incident Report, dated 08/23/24 indicated Administrator G was the reportee. The report indicated the offense was solicitation to commit - invasive visual recording in bathroom/changing room. The report indicated RN A was the offender. The report indicated the officer spoke with Administrator G and the DON. The report indicated the DON explained that RN A recorded a patient in secret. The report indicated Resident #1 liked to walk around in the nude and RN A had secretly recorded Resident #1 and sent the video through text to RN B and made jokes about Resident #1. RN A showed her co-workers the video while making fun of Resident #1. The officer asked RN B if she still had the video and was told that she had deleted it. The report indicated on 08/27/24 It was concluded by (the facility) that (RN A) had acted inappropriately by recording (Resident #1) and was subsequently terminated for that reason. According to the interviews, (RN A) was distributing the video to other employees and making comments like, When he was younger, he probably had big balls and Look what you're missing out on. RN A herself was interviewed and stated that her reasoning for recording (Resident #1) was to provide his nurse with information on his behavior. During an interview on 10/22/24 at 9:28 a.m. a family member of Resident #1 said the incident of RN A videoing Resident #1 had been reported to the police. He said the investigating officer was Officer J. He said RN A took a video of Resident #1 and shared the video with her co-workers. The family member said they had not personally seen the video. They said Officer J had seen the video. He said Officer J had interviewed some of the facility staff at the police department and had taken several phones. The family member said one of the phones had produced the video. The family member said they did not know which one had. The family member said the facility was aware of the incident in July 2024. The family member said they were not notified of the video until the end of August 2024. The family member said Resident #1 had no memory of the incident. The family member said Resident #1 cannot even remember what he had for breakfast. During an interview and observation on 10/22/24 at 1:30 p.m., Officer J said nursing home staff did not report the video to the police department until a month after it was recorded. He said then the following week, Resident #1's family had reported the video to the police department. He said the first report was made on 8/23/2024. He said review of the video indicated a create date of 7/26/24. He said the police department still had custody of CNA D's and RN B's cell phones. He said they each gave consent for their phones to be searched. He said the video was eventually found on RN B's cellphone. He said on some of the phones there were text messages from the staff members and RN A discussing what Resident #1 might have looked like when he was younger. The video was observed in Officer J's office. The video showed Resident #1 from behind. Resident #1's roommate was sitting in a chair. Each resident had their backs to the camera. Resident #1 had on a polo type shirt. He was naked from the waist down. His buttocks and testicles were visible. At one point in the video, Resident #1 walked over to his roommate and bent over as if to help him with something. When the resident bent over it further exposed his testicles. In the background, there was heard a female voice laughing off and on throughout the video. At one point the female voice said, What is he doing? followed by more laughter. During an observation on 10/22/24 at 2:00 p.m., a video of RN B being interviewed by Officer J revealed RN B stated RN A had sent the video to a few people. RN B said the video was, inappropriate to say the least. RN B said RN A sent the video to her between 07/21/24 to 07/28/24. RN B said she had deleted the video from her phone after she found out that compliance had called RN A. RN B said she had deleted text messages from her phone also. During an interview on 10/23/24 at 8:25 a.m., RN B said she went on vacation for a whole week. She said she then tested positive for Covid and was off another week. She said texted RN A to ask what she had missed at work. She said RN A said, Hey I'm about to send you a video. She said she watched most of the video but not all of it. She said this was normal behavior for Resident #1 and she had seen this behavior daily. She said she felt the video was inappropriate. She said she thought the video was meant to be humorous. She said she thought she typed back, LOL. She said after that she did not think anything else about the video. She said she was sick, and she really did not give it much thought. She said RN A texted her and told her she had sent the video to several other people. She said she did not know the date the video was sent to her, but it was towards the end of July 2024 because she was home sick. She said Resident #1 had a shirt on and nothing below. She said he was walking away from the camera. She said that was as far as she watched. She said she could see his buttocks. She said she did not have her glasses on and did not see his testicles. She said around 8/28/24 she did have a meeting with Compliance. She said she had already deleted the video from her phone. She said now the police had her phone. She said it was sent to forensics and they found the video on the phone. During an observation on 10/22/24 at 2:10 p.m., a video of CNA D was being interviewed by Officer J. CNA D said she was shown the video in the hallway right after RN A had come out of Resident #1's room. CNA D said that at the nurse's station RN A was showing the video to LVN C, LVN E, and herself. During an interview on 10/22/24 at 4:20 p.m., CNA D said RN A sent the video to her the day she recorded the video. She said this date was 7/27/24 on her birthday. She said the resident's roommate was in his wheelchair over by the air conditioner. She said Resident #1 was standing over him with a polo type shirt on and was naked from the waist down. She said she could see his buttocks, testicles, and his penis. She said RN A did not tell her why she took the video. She said she could not remember the context of her conversation with RN A. She said she could not remember if she saw all of the video, but she did feel it was inappropriate. She said she did not report the video to anyone. She said she was not aware of anyone else seeing the video. She said RN A never showed the video to LVN C, LVN E, and herself at the nurse's station. During an interview on 10/22/24 at 2:38 p.m., LVN C said RN A just showed her the video to show her what he was doing. She said the video was just the back of Resident #1 walking over to his roommate with just a shirt on. She said you could not see his face. She said you could see his testicles from behind. She said the video was never sent to her. She said she was at her medication cart when RN A showed her the video. She said LVN E and CNA D were at the facility but were not present when she watched the video. She said the resident's behavior was not a shock to her because he did stuff like that all the time. She said the video was inappropriate and was not necessary. She said RN A was laughing and said, I can't believe this, look at him. She said she did not report the incident. She said at the time she did not think RN A was going to do anything with it. She said at the time she did not think about it reporting it. She said she was not sure of the date the video was taken. She said she felt RN A showed it to her immediately after it was recorded. She said Resident #1 had dementia and would not remember the incident. She said one time he had even walked down the hall with only a shirt on. During an interview on 10/22/24 at 3:24 p.m., PTA L said she was aware RN A took a video of Resident #1. She said RN A showed her the video on her phone. She said she saw Resident #1 in his room naked from the waist down. She said he had only a shirt on. She said he was walking around the room. She said as soon as she saw it, she quit watching the video. She said she did not know if it was the day, RN A took the video. She said she worked at different facilities and was not sure of the day. She said residents across the hall had complained about Resident #1 walking around naked. She said she told RN #1 about the complaint and that was when she showed her the video. She said after viewing the video she did not report it to anyone. She said she did not know why. She said the video made her uncomfortable. She said, I just didn't. I don't know why. I just didn't want that in my brain. She said when RN A showed her the video she was laughing. She thought it was funny. She said Resident #1 was not aware the incident happened. During an interview on 10/22/24 at 3:56 p.m., Administrator G said what occurred was HR K informed him that a video was going around. He said that was either 7/31/2024 or 8/2/2024. He said he thought it was in August 2024. He said he could not remember if she gave him details of the video. He said the allegation did not hit his abuse and neglect radar. He said about two weeks later the DON was informed of the video and communicated the details the video to him and it was reported. He said RN A was suspended immediately and never brought back from suspension. He said he did send a text to the Treatment Nurse on 08/02/24. He said he did say the video was inappropriate. He said he just did not realize how bad the video was or the response would have been completely different. He said he had never seen the video. He said he left the facility sometime in August 2024. He said he was given the option to resign. During an interview 10/22/24 at 4:12 p.m., the Social Worker said she was not even aware of the video until compliance got involved. She said she usually did a checkup with residents after any incident. She said she did safe surveys and there were no concerns. She said she did talk to Resident #1. She said Administrator G had just come out of his room, so the incident was fresh on Resident #1's mind. She said he did not seem upset. She said he did say, I just don't know why someone would do something like that. I'm not going to let it affect me. She said she did get an order for psychology services to check on him. During an interview on 10/23/24 at 8:50 a.m., ADON H said she quit working at the facility on approximately 8/12/24. She said she became aware of the video in July 2024 on a Wednesday. She said the Treatment Nurse had told her. She said she told the Treatment Nurse that she needed to report the video to the DON and Administrator G. ADON H said she reported the video to Compliance on 8/3/24 at 2:00 a.m. She said therefore she was told about the video on 7/31/24. ADON H said she never saw the video. She said the Transport Aide did tell her on 08/09/24 that she had seen the video. She said she quit working at the facility because she felt things were not being addressed. She said there were a few other reasons. She said she understood the facility did not want a tag, but they had to do the right thing. She said she knew the DON was made aware of the video on 7/31/24 and HR K told her again on 8/12/24. During an interview on 10/23/24 at 9:14 a.m., HR K said she found out about the video on 8/2/24. She said ADON H told her about the video. She said RN A was going around showing everyone videos of Resident #1 walking around in his room butt naked. She said she immediately texted Administrator G. She said he said he texted her back and Oh no that is really bad. The family could sue us. Could you please tell the nurse's that is not funny, and they should not be doing that? She said nothing happened after that. She said there was no investigation. She said she reported it to the DON on 8/12/24 and voiced her concerns about nothing happening. She said, and still nothing was done. She said she never saw the video. She said she was told by multiple people it did exist and what it consisted of. During an interview on 10/23/24 at 9:31 a.m., the DON said she first became aware of the video approximately 2 days before she reported the incident to the state. She said HR K told her but did not tell her any details about the video. She said prior to 8/21/24 she had not even heard of the video. She said she was on vacation 7/30/24 - 8/5/24. She said the video was not reported to her during that time. She said on 8/22/24 she became of aware of the content of the video. She said she was told by the Staffing Coordinator. She said the Staffing Coordinator told her there was a video of Resident #1 with his genitals exposed and that RN A had taken the video. She said she suspended RN A immediately. She said she discussed the video with the Administrator G. She said he told her he had no idea about the video. She said she went back to HR K and asked her if she had reported the incident to Administrator G. She said HR K showed her a text message showing that she had reported the video to Administrator G. She said the text was dated 8/2/24. She said to her knowledge there was no investigation started by Administrator G. She said she began the investigation herself on 8/23/24. She said her investigation concluded that RN A had taken the video of Resident #1 and had shown multiple co-workers. She said RN A was terminated on 08/26/24. She said she had not seen the video. She said all staff that had knowledge of or saw the video was given final written warnings for failure to report. She said once she heard the content of the video, she felt it was abuse. She said she felt it should have been reported and investigated right from the very beginning. She said she did talk to Resident #1 about the video. She said he

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment are reported immediately or not later than 2 hours for 1 of 11 residents reviewed for abuse and neglect. (Resident #1) The facility staff (RN B, LVN C, CNA D, LVN E, the Staffing Coordinator, the Transport Aide, PTA L) failed to report abuse immediately to the Abuse Coordinator after they had viewed or became aware of video taken by RN A of Resident #1 naked from the waist down. Facility Administrator G failed to investigate and to report an allegation of abuse to the state agency after he became aware of the video on 07/31/24. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/26/24 and ended on 08/30/24. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for ongoing abuse and neglect. Findings included: Record review of a face sheet dated 10/22/24 revealed Resident #1 was an [AGE] year-old male and admitted on [DATE] with diagnoses including dementia, depression, and anxiety. Record review of a quarterly MDS dated [DATE] revealed Resident #1 was understood and usually understood others. The MDS revealed a BIMS score of 7, indicating severe cognitive impairment. The MDS indicated Resident #1 required supervision with most ADLs. Record review of Resident #1's physician's orders indicated on dated 08/23/24 indicated a verbal order was obtained to monitor for emotional distress every shift for 3 days. Record review of a care plan last revised on 10/12/24 revealed Resident #1 was at risk for impaired thought processes related to a history of dementia. Resident #1 needed assistance with all decision making. Resident #1 had an ADL self-care performance deficit related to decreased mobility and intermittent confusion. The care plan indicated Resident #1 had potential for a behavior problem as evidenced by inappropriate sexual behaviors. There was an intervention to provide privacy and encourage resident to remain clothed per family request. Record review of text messages dated 08/02/24 at 6:14 p.m., indicated texts between HR K and Administrator G. The texts indicated HR K wrote, .And ANOTHER note, I don't know who, how or where it originated from but there has been a video taken of (Resident #1) with no pants on and making its way around the building. Administrator G responded, Oh no! If you're still there, will you mention to one or two of the staff at the nurse's station that any videos taken of residents against their will can give family members a foot hold to sue whoever has the video. HR K responded, I left unfortunately but I was told over the phone, not in person at the facility or I would have said just that and how it's not funny. Administrator G responded, Mmm, ok. I'll mention it to (the Treatment Nurse). Record review of a text message dated 08/02/24 at 6:38 p.m., to the Treatment Nurse from Administrator G indicated, Hey, I just got word that there's an inappropriate video of (Resident #1) going around the facility. Will you mention to the staff that any videos taken of residents against their will can give family members a foot hold to sue whoever has the video. It has happened to our sister facility . Record review of a Grievance Resolution Form dated 08/23/24 indicated Resident #1 was involved in a video without his knowledge. The report indicated the compliance department was involved and notified administration. Record review of a Progress Note dated 08/23/24 indicated, SW (Social Worker) visited with resident (Resident #1) this afternoon .SW noticed no change in his mood or behavior after he was notified of the incident. He continues to show confusion, per his usual state. He states I am OK. I am not going to let this effect my life. He is agreeable to speaking with (psych services). SW has sent in a referral for evaluation and spoke with .counselor, re: the incident. SW will continue to monitor resident and will assist further as needed. The note was signed by the Social Worker. Record review of Nurse's notes for Resident #1 dated 08/23/24 - 08/28/24 indicated Resident #1 was monitored for mood and distress. The notes did not indicate Resident #1 had a change in mood or emotional distress. Record review of an Investigation Summary and Timeline report dated 08/30/24 indicated the DON was notified of the allegation of abuse on 08/22/24 at approximately 5:00 p.m. related to the conduct of RN A. The allegation suggested that the nurse had taken an unauthorized video of a resident. RN A was immediately suspended at the time it was reported, pending investigation. During the interview process, it was confirmed that RN A had taken a video of a resident while in his room The resident was not wearing pants and his genitals were visible. The Investigation Summary and Timeline indicated that Resident #1 had been interviewed by Administrator G and had knowledge of the video at the time of the interview. The Investigation Summary and Timeline report indicated RN A was terminated in person on 08/26/24. The report indicated the police were notified and the RP requested to press charges against RN A. Record review of a Provider Investigation Report dated 08/23/24 indicated that on an unknown date RN A took an unauthorized video of Resident #1. The investigation findings were confirmed. Record review of an interview of RN A dated 08/23/24 at 9:30 a.m. indicated she had taken a video of Resident #1. She stated Resident #1 had been in his room with his roommate. She said it had been reported to her by someone in therapy that they smelled smoke in the residents' room. She said she went to the room and Resident #1 was leaning over his roommate and his genitals were rubbing on the roommate. She stated the video showed Resident #1's backside, naked from the waist down. She said she showed the video to LVN C. She said the purpose of filming the video was to show LVN C the residents behavior. She stated, .I shouldn't have done that. I should have verbally told the nurse or done a progress notes. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by RN A. On 10/22/24 at 11:30 a.m., an attempt was made to reach RN A by telephone. There was no answer. A detailed message requesting a return call was left on voicemail. Record review of an interview of LVN C dated 08/23/24 at 10:10 a.m. indicated that she knew about and had seen the video. She said she had seen the video. She said it was of Resident #1 walking over to his roommate. She said Resident #1 only had a shirt on. She said she just saw the back of Resident #1. She said she saw his buttocks. She said he was bending over to do something, and she could see his genitals hanging down. She said RN A had shown her from her phone. She stated RN A said, Oh my God, look what (Resident #1) did. She said RN A thought it was funny. She said she did not report the video. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by LVN C. Record review of an interview of the Transport Aide dated 08/23/24 at 10:20 a.m. indicated the Transport Aide was aware of and had seen the video. She said the video was shown to her by RN A. She said the video was of Resident #1 walking with a shirt on. She said she could see Resident #1's genitals. The interview indicated that the Transport Aide asked RN A why she had the video and RN A said something to her about when he was younger, he probably had big balls. The Transport Aide said she had seen the video weeks ago. The interview indicated the Transport Aide did not report the video to anyone and when asked why she said, I know I should have. I don't know why I didn't. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by the Transport Aide. During an interview on 10/22/24 at 3:34 p.m., the Transport Aide said she walked in one morning. She said RN A said to come see the video and said, it's really funny. She said she did not understand why RN A would have even filmed the video. She said she watched the video on RN A's phone, and it was never sent to her. She said she thought the video was shown to her in July 2024. She said the video was inappropriate. She said on the video she saw Resident #1 over by the air conditioner. She said RN A said, Look at his balls going back in forth, I bet when he was younger, he was bigger. Record review of an interview of CNA D dated 08/23/24 at 10:20 a.m. indicated CNA D was aware of the video and that she had seen the video. She said it was both shown to her and sent to her via text by RN A. She stated that on the video Resident #1 was standing by his roommate with no pants or underwear on, just a shirt. Resident #1 leaned over to help his roommate and she saw his buttocks, penis, and scrotum. She said it had been less than a month since she had seen the video. She said she did not report the video to anyone. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by CNA D. Record review of an interview of LVN E dated 08/23/24 at 10:20 a.m. indicated LVN E had heard about the video but had not seen the video. He stated it had been about a month since he had heard about the video. He said he heard there was a video of Resident #1's genitalia. He said RN A had told him about the video. He said he thought he should have reported the video but did not report the video. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by LVN E. Record review of an interview of the Staffing Coordinator dated 08/23/24 at 11:05 a.m. indicated the Staffing Coordinator became aware of the video on 08/22/24. The Staffing Coordinator stated RN A came to the office and stated that compliance had called her about a video she had taken of one of the residents and she was scared and didn't know what to do. The Staffing Coordinator indicated she had not seen the video and had only heard gossip about the video. She said the staff that were gossiping did explain what was in the video. She said she did not report what was in the video because it was just gossip. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by the Staffing Coordinator. During an interview on 10/22/24 at 11:42 a.m., the Staffing Coordinator said she was in the hallway on a day in August 2024. She did not remember the date. She said RN A pulled her into the office and said compliance had reached out to her and she did not know what to do. The Staffing Coordinator said RN A was scared. The Staffing Coordinator said RN A said, I think they are calling me about the video. The Staffing Coordinator said she had heard rumors about the video but was not sure if those rumors were true. She said she has never seen the video. She said she heard there was a video out of a resident that they had at the time. She said she did not know any details. She said RN A did not tell her what was on the video or show it to her. She said she reported the incident to the DON after RN A had come into her office. Record review of a telephone interview of the Treatment Nurse dated 08/23/24 at 11:15 a.m. indicated the Treatment Nurse was aware of and had seen the video. She said it was shown to her right before she went on maternity leave. She said in the video she could see Resident #1's behind and his scrotum between his legs. She said RN A had shown her the video. She said it was on RN A's phone. The Treatment Nurse said she had mentioned the video to Administrator G and ADON H. She said she may have reported it the next day but could not remember. She stated that RN A thought the video was funny and was showing staff. She said she told RN A that the video was inappropriate, and she should not be videoing the residents. The interview was conducted and signed by the DON and the Clinical Resource Nurse. During an interview on 10/22/2024 at 1:06 p.m., the Treatment Nurse said she went on leave in August 2024 . She said it would have been the middle of August 2024. She said RN A did show her the video. She said RN A did not send her the video. She said RN A stopped her in the hall and said, Hey look at this. She said you could see Resident #1 and his roommate messing with the air conditioner. She said Resident #1 only had a shirt on. She said you could see his scrotum. She said the video was from behind and she was not sure if you could see the resident's penis. She said it did not appear Resident #1 was aware he was being videoed. She said RN A was laughing about the video. She said she told RN A it was inappropriate, and RN A said, I just thought it was funny. She said she did report it immediately to the previous ADON H that and told Administrator G the same day. She said she told Administrator G on 07/30/24 or 07/31/24. She said Administrator G told her he would address it at the next all staff meeting. Record review of a police Incident Report, dated 08/23/24 indicated Administrator G was the reportee. The report indicated the offense was solicitation to commit - invasive visual recording in bathroom/changing room. The report indicated RN A was the offender. The report indicated the officer spoke with Administrator G and the DON. The report indicated the DON explained that RN A recorded a patient in secret. The report indicated Resident #1 liked to walk around in the nude and RN A had secretly recorded Resident #1 and sent the video through text to RN B and made jokes about Resident #1. RN A showed her co-workers the video while making fun of Resident #1. The officer asked RN B if she still had the video and was told that she had deleted it. The report indicated on 08/27/24 It was concluded by (the facility) that (RN A) had acted inappropriately by recording (Resident #1) and was subsequently terminated for that reason. According to the interviews, (RN A) was distributing the video to other employees and making comments like, When he was younger, he probably had big balls and Look what you're missing out on. RN A herself was interviewed and stated that her reasoning for recording (Resident #1) was to provide his nurse with information on his behavior. During an interview on 10/22/24 at 9:28 a.m. a family member of Resident #1 said the incident of RN A videoing Resident #1 had been reported to the police. He said the investigating officer was Officer J. He said RN A took a video of Resident #1 and shared the video with her co-workers. The family member said they had not personally seen the video. They said Officer J had seen the video. He said Officer J had interviewed some of the facility staff at the police department and had taken several phones. The family member said one of the phones had produced the video. The family member said they did not know which one had. The family member said the facility was aware of the incident in July 2024. The family member said they were not notified of the video until the end of August 2024. The family member said Resident #1 had no memory of the incident. The family member said Resident #1 cannot even remember what he had for breakfast. During an interview and observation on 10/22/24 at 1:30 p.m., Officer J said nursing home staff did not report the video to the police department until a month after it was recorded. He said then the following week, Resident #1's family had reported the video to the police department. He said the first report was made on 8/23/2024. He said review of the video indicated a create date of 7/26/24. He said the police department still had custody of CNA D's and RN B's cell phones. He said they each gave consent for their phones to be searched. He said the video was eventually found on RN B's cellphone. He said on some of the phones there were text messages from the staff members and RN A discussing what Resident #1 might have looked like when he was younger. The video was observed in Officer J's office. The video showed Resident #1 from behind. Resident #1's roommate was sitting in a chair. Each resident had their backs to the camera. Resident #1 had on a polo type shirt. He was naked from the waist down. His buttocks and testicles were visible. At one point in the video, Resident #1 walked over to his roommate and bent over as if to help him with something. When the resident bent over it further exposed his testicles. In the background, there was heard a female voice laughing off and on throughout the video. At one point the female voice said, What is he doing? followed by more laughter. During an observation on 10/22/24 at 2:00 p.m., a video of RN B being interviewed by Officer J revealed RN B stated RN A had sent the video to a few people. RN B said the video was, inappropriate to say the least. RN B said RN A sent the video to her between 07/21/24 to 07/28/24. RN B said she had deleted the video from her phone after she found out that compliance had called RN A. RN B said she had deleted text messages from her phone also. During an interview on 10/23/24 at 8:25 a.m., RN B said she went on vacation for a whole week. She said she then tested positive for Covid and was off another week. She said texted RN A to ask what she had missed at work. She said RN A said, Hey I'm about to send you a video. She said she watched most of the video but not all of it. She said this was normal behavior for Resident #1 and she had seen this behavior daily. She said she felt the video was inappropriate. She said she thought the video was meant to be humorous. She said she thought she typed back, LOL. She said after that she did not think anything else about the video. She said she was sick, and she really did not give it much thought. She said RN A texted her and told her she had sent the video to several other people. She said she did not know the date the video was sent to her, but it was towards the end of July 2024 because she was home sick. She said Resident #1 had a shirt on and nothing below. She said he was walking away from the camera. She said that was as far as she watched. She said she could see his buttocks. She said she did not have her glasses on and did not see his testicles. She said around 8/28/24 she did have a meeting with Compliance. She said she had already deleted the video from her phone. She said now the police had her phone. She said it was sent to forensics and they found the video on the phone. During an observation on 10/22/24 at 2:10 p.m., a video of CNA D was being interviewed by Officer J. CNA D said she was shown the video in the hallway right after RN A had come out of Resident #1's room. CNA D said that at the nurse's station RN A was showing the video to LVN C, LVN E, and herself. During an interview on 10/22/24 at 4:20 p.m., CNA D said RN A sent the video to her the day she recorded the video. She said this date was 7/27/24 on her birthday. She said the resident's roommate was in his wheelchair over by the air conditioner. She said Resident #1 was standing over him with a polo type shirt on and was naked from the waist down. She said she could see his buttocks, testicles, and his penis. She said RN A did not tell her why she took the video. She said she could not remember the context of her conversation with RN A. She said she could not remember if she saw all of the video, but she did feel it was inappropriate. She said she did not report the video to anyone. She said she was not aware of anyone else seeing the video. She said RN A never showed the video to LVN C, LVN E, and herself at the nurse's station. During an interview on 10/22/24 at 2:38 p.m., LVN C said RN A just showed her the video to show her what he was doing. She said the video was just the back of Resident #1 walking over to his roommate with just a shirt on. She said you could not see his face. She said you could see his testicles from behind. She said the video was never sent to her. She said she was at her medication cart when RN A showed her the video. She said LVN E and CNA D were at the facility but were not present when she watched the video. She said the resident's behavior was not a shock to her because he did stuff like that all the time. She said the video was inappropriate and was not necessary. She said RN A was laughing and said, I can't believe this, look at him. She said she did not report the incident. She said at the time she did not think RN A was going to do anything with it. She said at the time she did not think about it reporting it. She said she was not sure of the date the video was taken. She said she felt RN A showed it to her immediately after it was recorded. She said Resident #1 had dementia and would not remember the incident. She said one time he had even walked down the hall with only a shirt on. During an interview on 10/22/24 at 3:24 p.m., PTA L said she was aware RN A took a video of Resident #1. She said RN A showed her the video on her phone. She said she saw Resident #1 in his room naked from the waist down. She said he had only a shirt on. She said he was walking around the room. She said as soon as she saw it, she quit watching the video. She said she did not know if it was the day, RN A took the video. She said she worked at different facilities and was not sure of the day. She said residents across the hall had complained about Resident #1 walking around naked. She said she told RN #1 about the complaint and that was when she showed her the video. She said after viewing the video she did not report it to anyone. She said she did not know why. She said the video made her uncomfortable. She said, I just didn't. I don't know why. I just didn't want that in my brain. She said when RN A showed her the video she was laughing. She thought it was funny. She said Resident #1 was not aware the incident happened. During an interview on 10/22/24 at 3:56 p.m., Administrator G said what occurred was HR K informed him that a video was going around. He said that was either 7/31/2024 or 8/2/2024. He said he thought it was in August 2024. He said he could not remember if she gave him details of the video. He said the allegation did not hit his abuse and neglect radar. He said about two weeks later the DON was informed of the video and communicated the details the video to him and it was reported. He said RN A was suspended immediately and never brought back from suspension. He said he did send a text to the Treatment Nurse on 08/02/24. He said he did say the video was inappropriate. He said he just did not realize how bad the video was or the response would have been completely different. He said he had never seen the video. He said he left the facility sometime in August 2024. He said he was given the option to resign. During an interview 10/22/24 at 4:12 p.m., the Social Worker said she was not even aware of the video until compliance got involved. She said she usually did a checkup with residents after any incident. She said she did safe surveys and there were no concerns. She said she did talk to Resident #1. She said Administrator G had just come out of his room, so the incident was fresh on Resident #1's mind. She said he did not seem upset. She said he did say, I just don't know why someone would do something like that. I'm not going to let it affect me. She said she did get an order for psychology services to check on him. During an interview on 10/23/24 at 8:50 a.m., ADON H said she quit working at the facility on approximately 8/12/24. She said she became aware of the video in July 2024 on a Wednesday. She said the Treatment Nurse had told her. She said she told the Treatment Nurse that she needed to report the video to the DON and Administrator G. ADON H said she reported the video to Compliance on 8/3/24 at 2:00 a.m. She said therefore she was told about the video on 7/31/24. ADON H said she never saw the video. She said the Transport Aide did tell her on 08/09/24 that she had seen the video. She said she quit working at the facility because she felt things were not being addressed. She said there were a few other reasons. She said she understood the facility did not want a tag, but they had to do the right thing. She said she knew the DON was made aware of the video on 7/31/24 and HR K told her again on 8/12/24. During an interview on 10/23/24 at 9:14 a.m., HR K said she found out about the video on 8/2/24. She said ADON H told her about the video. She said RN A was going around showing everyone videos of Resident #1 walking around in his room butt naked. She said she immediately texted Administrator G. She said he said he texted her back and Oh no that is really bad. The family could sue us. Could you please tell the nurse's that is not funny, and they should not be doing that? She said nothing happened after that. She said there was no investigation. She said she reported it to the DON on 8/12/24 and voiced her concerns about nothing happening. She said, and still nothing was done. She said she never saw the video. She said she was told by multiple people it did exist and what it consisted of. During an interview on 10/23/24 at 9:31 a.m., the DON said she first became aware of the video approximately 2 days before she reported the incident to the state. She said HR K told her but did not tell her any details about the video. She said prior to 8/21/24 she had not even heard of the video. She said she was on vacation 7/30/24 - 8/5/24. She said the video was not reported to her during that time. She said on 8/22/24 she became of aware of the content of the video. She said she was told by the Staffing Coordinator. She said the Staffing Coordinator told her there was a video of Resident #1 with his genitals exposed and that RN A had taken the video. She said she suspended RN A immediately. She said she discussed the video with the Administrator G. She said he told her he had no idea about the video. She said she went back to HR K and asked her if she had reported the incident to Administrator G. She said HR K showed her a text message showing that she had reported the video to Administrator G. She said the text was dated 8/2/24. She said to her knowledge there was no investigation started by Administrator G. She said she began the investigation herself on 8/23/24. She said her investigation concluded that RN A had taken the video of Resident #1 and had shown multiple co-workers. She said RN A was terminated on 08/26/24. She said she had not seen the video. She said all staff that had knowledge of or saw the video was given final written warnings for failure to report. She said once she heard the content of the video, she felt it was abuse. She said she felt it should have been reported and investigated right from the very beginning. She said she did talk to Resident #1 about the video. She said he did not remember the incident unless it was brought up by staff. She said she did feel like this was a dignity issue. She said he had been the mayor at one time. She said he was a photographer. She said he could not help his behavior. During an interview on 10/23/24 at 1:30 p.m. RN B said if this happened to herself or a family member, she would feel awful. She said, I would be so mad. During an interview on 10/23/24 at 2:21 p.m., a family member of Resident #1 said in the condition of dementia or Alzheimer's they would not know if this had happened to them. The family member said if they did know, they would feel it was demeaning or demoralizing and against all privacy. They said they thought the whole thing horrible. They said Resident #1 had been a very private but public person. The family member said Resident #1 was the mayor at one time. The family member said Resident #1 never discussed the birds and bees with them because he was a private person. The family member said Resident #1 would not have liked this at all. During an interview on 10/23/24 at 2:43 p.m., the Social Worker said if this happened to her or a family member she would be upset. She said she would probably feel embarrassed. During an interview on 10/23/24 at 3:00 p.m., the Treatment Nurse said this had happened to her dad she would be hell mad. She said the video was a dignity issue and abusive to the resident. During an interview on 10/23/24 at 3:18 p.m., CNA D if someone took a video of her or a family member naked, she would be livid. She said if it were her, she would feel humiliated. During an interview on 10/23/24 at 3:23 p.m., the Activity Director said if someone videoed her naked and shared it with others, she would be ashamed, mad, embarrassed and just pissed off. During an interview on 10/23/24 at 3:26 p.m., ADON F said she was a floor nurse when the video was taken. She said she never even heard about the video until there were in-services. She said if this happened to her or her family it would be upsetting. She said it was a modesty and dignity issue. She said it was a lack of respect. During an interview on 10/23/24 at 3:31 p.m., PTA L said if it happened to her, she would not like it at all. She said she would be extremely embarrassed and angry. She said she did take seriously that these are people's lives and they had feelings. During an interview on 10/23/24 at 3:46 p.m., LVN C said if someone took a video of her naked and shared it with other people, she would feel embarrassed and violated. During an interview on 10/23/24 at 4:02 p.m., LVN E said if this happened to family it would made him highly upset. He said he would be furious if it happened to him. He said it would be a total invasion of privacy. During an interview on 10/23/24 at 4:12 p.m., the Staffing Coordinator said if someone took a video of her naked and shared it with other people, she would feel embarrassed. During an interview on 10/23/24 at 4:21 p.m., the Clinical Resource Nurse said she learned of the video during one of her weekly visits. She said it was probably on 08/22/24 or 08/23/24. She said she was told there was a nurse that had taken an inappropriate video of a resident not fully dressed and that it was sent to a staff member that was not on duty that day. She said she interviewed RN A. She said RN A was off that day and she was told she had to come to the facility to be interviewed. She said RN A admitted to taking the video. She said during interview RN A said, there was no reason for taking the video. She RN A said during that interview she had shown the video to no one. The Clinical Resource Nurse said she never saw the video. She said RN A told her the video was no longer on her phone, and she had deleted the video. She said every staff member was in-serviced. She said there were some one-on-one in-services. She said these were with the people that were disciplined. She said RN A was suspended that day. She said RN A's license were referred to the state. She said if this happened to her, she would be humiliated. She said it would be humiliating regardless of her age. She said she was angry and very emotional about what happened. She said it was just disgusting. She said she had assisted with safe surveys and with Resident #1 and he had no concerns. She said she did know Administrator G had interviewed the resident. She said Administrator G told her the resident did not recall the incident. She said Administrator G was asked to resign or he would be terminated. During an interview on 10/23/24 at 4:45 p.m., the DON said if someone took a video of her naked and shared it with other people, she would feel absolutely disgusted, violated, and awful. During an interview on 10/22/24 at 4:46 p.m., Administrator M said he was not the administrator when the incident happened or when it was first reported. He said his first day was on 10/2/24. He said he would consider the video abuse. He said abuse sums it up. He said if it happened to him, he would feel terrified and abused. He said it was never something you wanted to see in your own facility. Record review of a Counseling/Disciplinary Notice dated 08/22/24 indicated an allegation of abuse was identified and RN A was suspended pending investigation. RN A was notified

Based on observation, interview, and record review the facility failed to ensure an effective pest control program so the facility was free of pests for 1 of 3 residents reviewed for pest control. (Resident #2) The facility had an outbreak of flies during the week of 5/23/24 through 6/5/24. On 6/1/24 a Resident #2 was noted with maggots in his wounds on his foot. This failure could cause the facility to become infested with pests. Findings included: Record review of Resident #2's Face Sheet indicated he was a [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were non pressure chronic ulcer of the right foot limited to the skin dated 4/16/22. Hemiplegia( paralysis on one side of the body)followed by a stroke muscle weakness, foot drop of the right foot, and mild cognitive impairment. Record review of Resident #2's Quarterly MDS dated [DATE] indicated intact cognitive status with a BIMs of 14. Resident #2's functional status was partial to maximum assistance with ADLs and sit up help with eating. Resident #2's skin condition did not indicate any pressure ulcers. Record review of Resident #2's Care Plan last revised 4/10/24 indicated a Focus area of wound to the right first and second toe. Some of the interventions were identify and document potential causative factors and eliminate or resolve where possible. Provide treatment as ordered, and wound care as ordered. A Focus area of Resident #2 reflected he had the potential for pressure ulcer development. Some of the interventions were to administer treatments as ordered and monitor effectiveness. Record review of Resident #2's computerized physician's orders indicated an order dated 6/1/14 indicated cleanse first and second toe with wound cleanser or normal saline , pat dry and apply methylene blue and cover with dry dressing. An order dated 6/12/24 indicted to clean right fifth toe with wound cleanser or normal saline, pat dry , apply Medi honey and cover with dry dressing. Record review of the facility last pest control log dated 5/23/24 indicated it was a monthly pest control visit and they targeted house flies, and ants. Record review of Resident #2's nursing notes dated 6/1/24 at 8:01 p.m. signed by LVN D. indicated upon wound care this shift, the nurse removed the dressing dated 5/31/24 from the wound care on previous day and maggots were noted inside the residents wound between the right toe and second toe. Wound care was performed as ordered by the physician, as well as cleaning between each of the resident's toes on the right foot. The resident stated his level of pain during wound care was 10/10. The wound itself was bright red and inflamed but not much drainage noted this shift. A clean dressing was applied the family member was at the bedside with the resident at this time of the occurrence and was aware. The DON, the Physician, and Wound Care Physician were notified with no new orders at this time. ( Attempted to contact LVN D several times by phone and she would not answer or return calls or texts.) Record review of Resident #2's the Wound Physician notes dated 6/4/24 indicated non pressure wound to the right second toe with full thickness with a duration of greater than 939 days. The wound size was 4.6 cm by 3 cm by 0.1 cm. with a surface are of 13.80 cm, moderate exudate(a watery fluid that can appear clear or pale yellow in color and is normally part of the healing process during the inflammatory stage of a wound) , 10 percent slough( dead tissue separating from living tissue and 90 percent granulation tissue( new connective tissue). The wound progress had improved as evidence by decreased surface area. A lymphatic wound( wound occurs when lymph nodes or vessels in lymphatic system are damaged or blocked) to the right first toe( Great toe or big toe) with full thickness duration greater than 127 days. The wound size was 2 cm by 1 cm by 0.1 cm with the surface are of 2/00 cm, moderate serous exudate, 100 percent granulation tissue, wound progress improved as evidenced by decreased drainage. The dressing treatment for both the wounds was methylene blue foam apply once daily for 23 days. A lymphedema wound of the right fifth toe( little toe) with duration of greater than 4 days. The wound measured 0.4cm by 0.3cm by 0.1 cm. the surface area was 0.12 cm with light serous drainage and 100 percent granulation( new healthy tissue). Record review of a purchase order dated 6/5/24 indicated the facility purchased 6 wall sconce fly light traps for capturing flies, moths, gnats, mosquitos, and other flying insects. During an interview on 6/19/24 at 9:10 a.m. Resident #5 said they did have problems with flies a few weeks ago but they appear to all be gone now. During an interview on 6/19/24 at 9:12 a.m. Resident #6 said she saw a fly every now and then but had no issues with flies. During an interview on 6/19/24 at 9: 20 a.m. Resident #2 was in wheelchair with wheeling himself around using his hand and left foot. He is eating breakfast unassisted. His tray was on a table across the room. He was wheeling back and forth. He said he did not require assistance. He said that he had trauma to his toe because he had hit his foot on something. He had on socks. Observation of the room did not reveal any flies. During an interview on 6/19/24 at 9:35 a.m. Resident #7 said he was doing well and had no problems he was noted with a fly squatter on his side of the room. He said a few weeks ago they had quite a few flies, but now there was only and occasional fly here and there. During an interview on 6/19/24 at 10:30 a.m. CNA E said Resident #2's foot is always covered with a bandage. She said she had no idea what his wounds looked like. When they give him a shower, they put a plastic bag on the foot to keep it dry. CNA E said they did have a problem with flies a few weeks ago but they were better now. During observation on 6/19/24 at 10:45 a.m. a fly was observed in the conference room. During an observation and interview on 6/19/24 at 11:41 a.m. revealed Resident #2's wound care was completed by LVN A and the ADON. Resident #2 was sitting up in his wheelchair. The ADON held his right foot while LVN A removed his sock. The resident had a bandage that covered all his toes. The LVN removed the bandage. Observation of his foot revealed the whole foot was swollen past the ankle and it was swollen more toward the toe area, and under the bottom of his foot. The first and second toes were deep purple, and the reddish color was on the top of the foot about half an inch high. The first toe had a wound on the inside appeared to be discoloration between that toe and the second toe. The first toe had an area with no skin and a black toenail. The second toe was completely discolored, purple in color, with the skin looking beefy, and the nail bed was white. There was a black spot on the outside of the fifth toe. LVN A cleansed the wounds with wounds cleanser to right foot 1st and 2nd toe, gently patted dry, applied 2 dry pieces of Hyrofera Blue between toes and draped over the toes and covered with a dry dressing. She applied Medi honey to fifth and covered with a dry dressing. During a telephone interview on 6/19/2024 at 12:08 p.m. the Treatment Nurse/LVN B said LVN D had called her on a Saturday 6/1/24 a couple of weeks ago, to say she had found maggots in Resident #2's wound. The Treatment nurse said she told LVN D to call the DON and physician for orders. The Treatment Nurse said when she arrived at the facility on that Monday, she did not see any maggots and the resident had been seen by wound care on at least two occasions since and there were no problems noted. During an interview on 6/19/2024 at 12:38 p.m. the DON said she had been informed by LVN D that Resident #2 had maggots in his wound on 6/1/24. She said she had informed the LVN to write a factual note and not speculate about what may have occurred. She said she told LVN D to contact the physician and there were no new orders. She said on one day Resident #2 had maggots in his wound and the next day they were gone. They had problems with flies but had installed blue lights at the entrances of the facility and the flies were much better. She said the wound was covered and she had no idea how the maggots got in the wound. She said she had not seen any maggots in Resident #2's wound. During an observation on 6/19/24 at 3:00 p.m. a fly was noted flying around the nurse's station. During an interview on 6/19/24 at 5:24 p.m. the administrator there was an incident when Resident #2 was found with maggots. He said that they had quite a bit a rain and with that rain came the flies. They had put in 6 to 8 blue lights to prevent insects from coming in the building. They no longer had problems with flies just an occasional one here or there. He said he could only speculate about how Resident #2 got the maggots in his wound. During a telephone interview on 6/28/24 at 2:57 p.m. the Administrator said they had pest control out for the flies and they put in the blue lights to combat the fly problems. They ordered the lights, and they were installed and they had no farther issues with flies. During a telephone interview on 6/28/24 at 3:07 p.m. the Treatment Nurse said she provided wound care to Resident #2 on 5/31/24 and she did not see any maggots. She said she did not think she saw any flies in the room. She performed wound care according to physician's orders. The Treatment Nurse said she did not remember leaving the room because she brought all her supplies into the room with her. She said she did not know how Resident #2 got the maggots in his wound because his wounds were always coved with a bandage and most of the time he had on a sock as well. According to Terminix.com fly eggs take 8- 20 hours to become maggots.

Based on interview and record review, the facility did not ensure residents had the right to be free from involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms for 1 of 4 (Resident #1) residents reviewed for involuntary seclusion. The facility failed to follow their policy for residents refusing the test for COVID-19 resulting in Resident #1 being placed in isolation from 7/18/23 through 8/18/23 (32 days), 10/3/23 through 10/16/23 (13 days), and 11/6/23 through 11/11/23 (6 days). This failure could place residents at risk for increased depression and emotional and psychological harm. Findings included: Record review of the face sheet dated 2/22/24 indicated Resident #1 admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), hemiparesis (partial weakness to one side) and hemiplegia (paralysis to one side) following cerebral infarction affecting the left side, dementia, muscle weakness, and lack of coordination. Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 09 and was moderately cognitively impaired. The MDS indicated Resident #1 used a wheelchair for mobility. Record review of the care plan last updated 12/1/23 indicated Resident #1's family requested for him not to be tested for COVID-19 starting 7/27/23. The care plan indicated interventions were in place including patient to stay in room while during COVID outbreak starting 12/1/23. Record review of a nursing progress note dated 7/27/23 at 7:42 a.m. written by the DON indicated, Family continues to refuse to have [Resident #1] tested for COVID despite facility outbreak. [Resident #1's family] educated on [the] risks of not identifying [a] COVID infection. [Resident #1's family] continued to refuse. Will continue to encourage [the family] to consider testing should symptoms arise. Record review of a nursing progress note dated 7/27/23 at 10:42 a.m. written by the DON indicated, [The] Ombudsman [was] notified of [the] family's refusal [for Resident #1] to participate in [COVID] testing. [The] Ombudsman stated [Resident #1] should be treated like a positive [COVID] case and [Resident #1 needed] to remain in isolation until [the COVID] outbreak was over or [the] family agreed to outbreak testing [for Resident #1]. Record review of a nursing progress note dated 8/15/23 at 11:13 a.m. written by the DON indicated, [Resident #1's family] in facility at this time requesting [Resident #1] be allowed out of room. [Resident #1's family was educated] on COVID outbreak in facility and .due to family request for resident to not be tested for COVID, resident would be treated as if they were COVID positive for the duration of the outbreak as previously agreed upon. [Resident #1's family was] upset with [the] isolation of [Resident #1] and requesting exception be made. Education [was] provided to [Resident #1's family] regarding CMS guidelines and need for maintaining safety of all residents within facility. Educated [Resident #1's family he] would be allowed out of room once outbreak period was over or [if Resident #1] had a negative COVID test. [Resident #1's family was] visibly upset at this time and left DON's office. Record review of a nursing progress note date 10/3/23 at 11:21 a.m. written by RN B indicated, [Due to a] Covid outbreak and family's refusal to allow testing, [Resident #1] was to be treated as Covid positive until we are out outbreak. Family has been notified and wife verbally complied. During an interview on 2/13/24 at 11:47 a.m. the Ombudsman said she felt there was a miscommunication with the facility regarding the COVID outbreak. The Ombudsman said Resident #1's family refused to for him to be COVID tested . The Ombudsman said she had advised the facility he had the right to refuse but they could put him in quarantine for 10 days to watch for signs and symptoms. The Ombudsman said the facility restarted Resident #1's quarantine time every time during the initial outbreak that another resident tested positive for COVID. The Ombudsman said the facility ended up keeping Resident #1 in quarantine for 7 weeks. During an interview on 2/14/24 at 10:12 am LVN C said he was not familiar with Resident #1. LVN C said Resident #1 was not on his hall during his admission to the facility. LVN C said if a resident tested positive for COVID they would be placed in isolation with contact precautions in place. LVN C said if a resident refused to be COVID tested they would be placed in isolation for approximately 5-7 days. LVN C said if a resident was non-compliant with isolation, they would encourage them to keep distant from other residents and wear a mask. LVN C said a resident could not be forced to stay in their room. During an interview on 2/14/24 at 10:17 a.m. RN B said she was familiar with Resident #1. RN B said the family did not want him tested for COVID. RN B said when the facility had a COVID outbreak in the summer of 2023 Resident #1 was placed in isolation due to refusal to test for COVID. RN B said the outbreak lasted approximately 2 months. RN B said she did not remember the exact length of Resident #1's isolation, but it was quite a while. RN B said the Administrator had discussed the isolation with Resident #1's POA. RN B said Resident #1 was not allowed out of his room during his isolation. RN B said the family would sneak him out of his room and take him outside. RN B said the Administrator went outside each time the family took Resident #1 outside and told them they were not allowed to be out of the room and need to go back due to Resident #1 being in isolation. RN B said a resident that tested negative for COVID and was symptomatic would be placed on isolation for 7 days. RN B said she thought a resident who tested positive for COVID would be placed in isolation for 7-10 days. During an interview on 2/14/24 at 1:23 p.m. the family said they were not informed of Resident #1's isolation status during the COVID breakout during summer 2023. The family said the DON told them she had been told by the Ombudsman to isolate Resident #1 for the entire time of the COVID outbreak due to refusal of COVID testing. The family said the Ombudsman denied telling the DON that Resident #1 had to isolated during the entire COVID outbreak. During an interview on 2/15/24 at 9:33 a.m. the Infection Preventionist said she had been the infection preventionist at the facility for a couple years. The Infection Preventionist said she performed the COVID testing on residents. The Infection Preventionist said Resident #1 had been COVID tested in the past prior to a care plan meeting with the social worker where the family requested no COVID testing moving forward. The Infection Preventionist said if a resident tested positive for COVID they would be moved to a different room and placed in isolation for 10 days as long as symptoms were not worsening. The Infection Preventionist said if a resident had been exposed to COVID, was symptomatic or asymptomatic, but tested negative for COVID they would not be placed in isolation they would only be monitored and tested as needed. The Infection Preventionist said they could not isolate someone who tested negative. The Infection Preventionist said if a resident refused to be tested for COVID during an outbreak they would be treated as if they were an unknown COVID positive and be required to be in isolation for the duration of the outbreak. The Infection Preventionist said if a resident was non-compliant with isolation staff would re-educate them, put a mask on the resident, and redirect them back to their room. The Infection Preventionist said she was on leave during the outbreak which started at the end of June 2023, but that Resident #1 should have been in isolation for the duration of the outbreak due to refusal to test for COVID. During an interview on 2/15/24 at 10:34 a.m. CNA D said if a resident tested positive for COVID they would be placed in isolation and staff would wear N95 masks while in the building. CNA D said the COVID positive resident would be in isolation for 10-12 days. CNA D said if a resident was exposed to COVID but tested negative for COVID they would not be moved or put in isolation. CNA D said Resident #1 was the only resident she was ever aware of refusing to be COVID tested . CNA D said Resident #1 was placed on isolation in the summer 2023 during a COVID outbreak for the duration of the outbreak. During an interview on 2/15/24 at 10:38 a.m. LVN E said she had worked at the facility for [AGE] years. LVN E said if a resident tested positive for COVID they would be placed in isolation, the facility would begin outbreak testing, and staff would wear N95 masks while in the facility. LVN E said a COVID positive resident would be in isolation for 10 days. LVN E said if a resident was exposed to COVID, was symptomatic, and tested negative for COVID they would be placed in isolation for 7-10 days or until they were no longer symptomatic. LVN E said if a resident refused to be COVID tested and were asymptomatic they would be put in isolation because the facility would not know if they were COVID positive. LVN E said a resident who refused to be COVID tested would be in isolation until they agreed to be tested . LVN E said if a resident was non-compliant with isolation staff would educate the resident, contain to illness, wound, etc., and perform/encourage frequent hand hygiene. During an interview on 2/15/24 at 12:58 pm the DON said if the facility had a COVID positive resident they would begin outbreak testing on days 1.3. and 5 and isolate the COVID positive resident for 10 days. The DON said in July 2023 the facility was considered in outbreak until they went 14 days without a COVID positive test. The DON said if a resident had been exposed to COVID, was symptomatic, and tested negative they would not be put in isolation. The DON said if a resident refused to test for COVID they would be put in isolation until the facility was out of outbreak. The DON said Resident #1 refused to be COVID tested and was placed in isolation for the duration of the outbreak that occurred in the summer of 2023. The DON said Resident #1 was asymptomatic during the isolation and outbreak. The DON said Resident #1 only interacted with other resident while in therapy, when eating in the dining room, and sometimes when brought to activities by his family, but for the most part was not around other residents a lot. The DON said if the facility had ended Resident #1's isolation after 10 days and they were still in outbreak he would have been re-exposed and required another 10-day isolation. The DON said Resident #1 was isolated during the facility's COVID outbreak in November 2023. During an interview on 2/20/24 at 1:06 p.m. Resident #1's family said on 8/16/23 they took Resident #1 outside and were yelled at by the DON to go back to the Resident #1's room. The family said Resident #1 started crying when the DON yelled at them . The family said during the October COVID isolation Resident #1 was isolated for 3 weeks after they had been told it would only be a 14-day isolation. They said Resident #1 was put in isolation again in November due to another COVID outbreak at the facility and refusal to COVID test. The family said during one of his isolations they had taken Resident #1 outside to the front porch of the facility and away from other residents. The family said the Administrator came out and told them they could not be outside or out of the room. The family said she asked why as they were not near any other person. The family said they were wearing masks at the time. The family said the Administrator said something about Resident #1 shedding and it was blowing towards him, and he could get COVID from the shedding. The family said the Administrator continued to stand there looking at them and Resident #1 began to get upset so she reluctantly took Resident #1 back to his room. During an interview on 2/21/24 at 1:15 p.m. the DON said during his isolation Resident #1 was permitted to go outside. The DON said there were stipulations on him going outside. The DON said the stipulations included Resident #1 had to wear a mask when transporting through the facility and had to come back in or wear a mask if other residents were outside. The DON said there were only 2 sitting areas outside and she guessed they were only about 4 feet apart, but she had not measured it. Record review of the facility's Freedom from Abuse, Neglect, Exploitation policy revised 12/2023 indicated, It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. It is also the policy of this facility to recognize the resident right to personal privacy and confidentiality of their physical body personal care, and personal space or accommodations. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms .Involuntary seclusion is separation of a resident from other residents or from his/her room or confinement to his/her room (with or without roommates) against the resident's will, or the will of the resident's representative . Record review of the facility's COVID-19 Testing policy revised 10/2022 indicated, It is the policy of this facility to provide or obtain laboratory testing services for residents and staff to assist in the identification and management of COVID-19 infections and/or outbreaks. Testing will be performed according to current local/state health departments and Centers for Disease Control and Prevention guidelines .Resident declines: Resident or resident representatives my exercise their right to decline COVID-19 testing. A. If a resident has known exposure to COVID-19 or is symptomatic regardless of vaccination status and declines testing, the resident will be placed on transmission-based precautions (TBP) until criteria for discontinuation is met. B. If outbreak testing has been triggered and an asymptomatic resident refuses testing, the facility should be extremely vigilant, such as through additional monitoring, to ensure the resident maintains the appropriate distance from the other residents, wears a face covering, and practices effective hand hygiene until the procedures for outbreak testing have been completed . Record review of the facility's undated Transmission Based Precaution and Isolation policy indicated, It is the policy of [the facility] to implement infection control measures to prevent the spread of communicable disease and conditions. Int LTC, it is appropriate to individualize decisions regarding resident placement (shared or private), balancing infection risks with the need for more than one occupant in the room, the presence of risk factors that increase the likelihood of transmission, and the potential for adverse psychological impact on the infected or colonized resident. It is therefore appropriate to use the least restrictive approach possible that adequately protect the residents and others. Maintaining isolation longer than necessary may adversely affect psychosocial well-being .

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision to prevent accidents for two of two residents (Resident #1 and #2) reviewed for accidents and hazards in that: 1. The facility failed to update Resident #1's elopement evaluation after he exhibited exit seeking behavior, and Resident #1 was able to elope from the facility without staff's knowledge due to an exit door failing to activate and Resident #1 was found on the roadway by police 2. The facility failed to ensure coffee was served at a safe temperature for Resident #2. Resident #2 received second degree burns to the left arm and abdomen after hot coffee was spilled on her. Resident #2 was not thoroughly assessed for burns after the coffee was spilled and treatment was not provided to the abdominal burn until 2 days after the incident occurred 3. The facility failed to have a policy to ensure coffee temperatures were at the appropriate temperature prior to serving These failures resulted in the identification of an Immediate Jeopardy (IJ) on 09/12/23 at 02:06 PM. While the IJ was removed on 09/13/23 at 1:45PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place the residents at risk for further elopement, burns, serious harm, serious injury, or death. Findings included: 1. Record review of Resident #1's face sheet, dated 09/11/23, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included generalized muscle weakness (decreased strength and compromised ability to perform active movements), type 2 diabetes mellitus (a long-term medical condition in which your body doesn't use insulin properly, resulting in unusual blood sugar levels), and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Record review of Resident #1's admission MDS assessment, dated 02/20/23, indicated he did not have a BIMS conducted because he was rarely/never understood. He had problems with both short-term and long-term memory, and his cognitive skills for daily decision making were severely impaired. He required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. He required supervision assistance with eating. Resident #1's locomotion on and off unit were not coded in the assessment because he had only performed those activities once or twice during the assessment. He used a wheelchair as a mobility device. Resident #1 received antidepressant medications 7 of 7 days of the assessment. Record review of Resident #1's care plan, created and initiated on 03/27/23, indicated a focus of elopement risk/wanderer related to disoriented to place, history of attempts to leave facility unattended, impaired safety awareness, resident wanders aimlessly. Interventions included: *Assess for fall risk *Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book *Document wandering behavior and attempted diversional interventions *Establish behavior patterns in the resident: look for patterns in the places the resident wanders repeatedly, what time of day they tend to wander most, and if the resident was engaging in a particular activity prior to wandering. *Monitor fatigue and weight loss *Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes *Redirect them once you have distracted them: once you have gained their attention, redirect them in an assuring manner Further record review of Resident #1's care plan, created and initiated on 02/20/23, indicated a focus of at risk for falls related to decreased mobility and poor safety awareness. Interventions included: *Avoid rearranging furniture *Be sure the call light is within reach and encourage to use it to call for assistance as needed *Bed in lowest position *Educate resident/family/caregivers about safety reminders and what to do if a fall occurs *Ensure resident is wearing appropriate footwear when ambulating or wheeling in wheelchair *Needs a safe environment: floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; side rails as ordered, handrails on walls, personal items within reach Record review of Resident #1's progress note, dated 03/21/23 at 09:49AM, stated: resident going into other rooms, per resident that is [alert and oriented] went into her room last night, attempted to go into kitchen this am but staff present and redirected, shower given this am. Record review of Resident #1's progress note, dated 03/21/23 at 01:03 PM, written by RN H, stated: Resident propelled self using wheel chair to hall one exit door. Resident pushed the door attempting to exit setting off the alarm. This nurse turned off the alarm and redirected the resident back to the nurses station. Record review of Resident #1's progress note, dated 03/23/23 at 02:21 PM, stated: noted resident going into others room, per other staff members taking belonging from other rooms, belongings returned Record review of Resident #1's progress note, dated 03/24/23 at 05:45 PM, written by LVN G, stated: [Resident] attempted to go out back door on hall 400. Staff quickly redirected [Resident]. Alarm reset. [Resident] wanders, propels self in wheelchair. Record review of Resident #1's progress note, dated 03/25/23 at 03:47PM, written by LVN G, stated: [Resident] has attempted to go out door on hall 100 & hall 300 today. Sat at front door attempting to open door unsuccessfully. Record review of Resident #1's progress note, dated 03/27/23 at 09:46AM, stated: Up in [wheelchair] and propels self .continues to attempt to go into others room Record review of Resident #1's progress note, dated 03/28/23 at 05:02 AM, stated: Received call from [facility's city police department] that a [name of facility] patient was on [local farm-to-market road] in a [wheelchair]/ This nurse and 2 CNAs went out to road to find patient in [wheelchair] on the side of the road by the driveway turn in. Spoke with police, thanked him and brought patient via [wheelchair] back into building. No alarms went off. No employees let him out. Patient placed in bed. 15 min check in place. DON notified. Will continue to monitor. Record review of Resident #1's elopement / wandering evaluation, signed on 02/13/23, indicated Resident #1 was a low risk. Record review of Resident #1's elopement / wandering evaluation, signed on 03/28/23, indicated he was a high risk. Record review of Resident #1's incident report, dated 03/28/23, indicated the city police had called the facility and informed them that a patient was on the road in front of the facility in a wheelchair. A nurse and two CNAs went out and brought the resident back into the facility. There were no injuries observed. He had a predisposing situation factor of being an active exit seeker and a wanderer. Record review of the facility's provider investigation report for Resident #1's elopement stated in the second investigation summary section: .Evaluation of facility doors revealed the door alarm closest to the resident's room was not activated at the time of his elopement . During an interview and observation on 09/11/23 at 1:58 PM, the Maintenance Director said he was working in the facility when the resident eloped in March 2023. He said the resident got out because the doors did not lock at the time of the incident. He said he was unsure if the alarm went off or not at the time of the incident. He tested all of the door alarms weekly, sometime during the week. He said he did not check on a specific day. He said he kept the checks on a log. He said the front and the back door were secured and alarmed. He said before the elopement, only the front and back door were secured. He said the other doors were only alarmed but not locked. They could still be pushed opened to allow egress. He said the nurses and the Maintenance Director had a key to the alarm. He said after the elopement all exterior doors were upgraded so they could be secured in the same way as the front and back door with a magnet lock. They were all alarmed. He took this surveyor around the facility and checked each exterior door and they were all secured and alarmed. During an interview on 09/11/23 at 2:58 PM, CNA M said she remembered seeing Resident #1 around 3:00 AM. She said she missed out on everything because the others ran outside. She said the nurses had a key to the alarms. She said she had never seen anyone turn off the alarm. She said she thought they were always on. She said she never heard an alarm sound that morning when the resident eloped. During an interview on 09/11/23 at 3:04 PM, CNA L said Resident #1 had behaviors before of exit seeking and trying to exit. She was not sure how he got out of the facility at the time of the elopement. She said he got out and they noticed he was missing and ran out to look for him and they found him at the end of the parking lot next to the road. She said he did not exhibit any distress. They got him back inside and the nurse looked him over. She said she was not sure if she heard an alarm that morning. She said the nurses had a key to the alarms. During an interview on 09/11/23 at 3:14 PM, CNA K said she dressed Resident #1 that morning. She said she brought him to the front of the building near the nurses station and gave him some snacks to keep him occupied. She said he then wandered around the facility either to the dining room or another hall. When she came back to check on him, he was not in the same spot when she left him. She said she could not find him in his usual places. The PD called and he was out of the facility down beside the street. They found him out of the parking lot by the side of the street. She said he did not have any injuries. She said they brought him back into the facility. She said later that day after her shift the DON or the ADON called her and they said the 400 hall door was found unlocked. She said she never heard an alarm that morning. She said she last saw him around 5-10 minutes before they found him outside. She said the nurses and the ADON have a key to the alarms. She said he just mumbled when asked how he got out. During an interview on 09/11/23 at 3:25 PM, LVN B said she said took care of Resident #1 the next shift after his elopement. She said he did not have any negative effects and did not have any injuries related to the elopement. During an interview on 09/11/23 at 3:29 PM, the ADON said Resident #1 got out of the building. She said the nurse assessed him. She said Resident #1 had no negative effects. She said he was outside around 10-20 minutes. She said they put him on 1:1 observation until he left to another facility later that day on 03/28/23. During an interview on 09/11/23 at 3:32 PM, the DON said she headed the facility's investigation. She said one of the nurses found that the alarm was turned off after Resident #1's elopement. She said when she arrived to the facility on [DATE], she checked the doors and the alarms were activated. She said one of the nurses that were working at the time of the elopement told her that the alarm to the 400 hall was turned off. She said the 400 hall door was the only one that was found not activated. She said the nurses had a key at the time of the elopement. She said after the incident, they changed the door locks to magnets that auto lock. She said Resident #1 was put on 15-minute checks until he was transferred out to another facility. She said they reevaluated all elopement risk residents. She said they did in-services related to the alarms. She said her investigation found that the resident was out of the building about 20-25 minutes. She said the current administrator had only been there about 1 month. During an interview on 09/11/23 at 4:00 PM, the DON said they did not have a policy that addressed how often the door alarms should be checked. During an observation on 09/11/23 at 4:16 PM, this surveyor found a speed limit sign for the road that the facility driveways end on. The speed limit was 55 miles per hour. During an interview on 09/11/23 at 4:43 PM, RN H said he did not remember taking care of Resident #1. He said he wrote a progress note on 03/21/23 likely because he noticed the resident was exit seeking. He said he could not recall the event but he said he would have notified the nurse and the DON about the new exit seeking behaviors. He said he was unsure if a new elopement assessment was completed on Resident #1 related to his exit seeking. During an interview on 09/11/23 at 4:49 PM, LVN G said Resident #1 was frequently exit seeking. She said she kept a closer eye on him since he started exit seeking. She said the hall doors had alarms and would sound when someone opened the door. She said she was unable to remember if a new elopement assessment was completed or if the DON was notified about Resident #1's exit seeking behaviors. She said for a resident that was a low risk to elope and then started to be exit seeking, she said she would notify the DON and complete a new elopement risk assessment. She said she did not create a new elopement/wandering risk assessment for Resident #1 when she noticed his exit seeking behaviors. During an interview on 09/12/23 at 9:09 AM, the DON said she last conducted an elopement in-service in March 2023 after Resident #1 eloped. She said newly hired employees were taught about elopement during their orientation training. She said she expected to be notified about Resident #1's new exit-seeking behaviors prior to his elopement. She said she expected the nurses to complete a new elopement assessment when they noticed new exit-seeking behaviors. During an interview on 09/12/23 at 9:14 AM, the Administrator said he did an in-service on elopement with the nurses on 09/11/23 after this surveyor left the facility. 2. Record review of Resident #2's face sheet, dated 09/12/23, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included generalized muscle weakness (decreased strength and compromised ability to perform active movements), and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Record review of Resident #2's quarterly MDS assessment, dated 07/03/23, indicated she did not have a brief interview for mental status conducted because she was rarely/never understood. Her staff assessment for mental status indicated she had a problem with both short and long-term memory, and that her cognitive skills for daily decision making were severely impaired. She did not exhibit behaviors of rejection of care or wandering. She required extensive assistance with bed mobility, transfers, locomotion on and off unit, dressing, eating, toileting, and personal hygiene. Her primary medical condition that best described her primary reason for admission was non-traumatic brain dysfunction (a brain injury not caused by external physical force or trauma exerted on the head). Record review of Resident #2's physician's orders, dated 09/12/23, indicated he had these orders: *Cleanse left arm wound with normal saline/wound cleanser, apple silver sulfadiazine cream (used with other treatments to help prevent and treat wound infections in patients with serious burns) to left arm BID and cover with kerlix (a brand of gauze that is used to cover wounds) every shift for wound healing. The start date was 07/07/23. *Cleanse lower left abdomen wound with normal saline/wound cleanser, apply silver sulfadiazine cream to left arm BID and cover with kerlix every shift for wound. The start date was 07/09/23. Record review of Resident #2's care plan, created on 07/10/23, indicated a focus of Resident #1 has actual impairment to skin integrity related to burn to left arm from spilt coffee. The focus also indicated 07/09/23 burn areas noted on abdomen - resident refusing treatment frequently due to impaired cognition. Interventions included: *Notified wound MD, orders implemented *Educate resident/family/caregivers of causative factors and measures to prevent skin injury. *Follow facility protocols for treatment of injury *Identify/document potential causative factors and eliminate/resolve where possible *Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs or symptoms of infection, maceration to MD. Further record review of Resident #2's care plan, created on 07/25/2019, indicated a focus of Resident #2 is at risk for impaired cognitive function/dementia or impaired thought processes. Interventions included: *Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions. Use simple, directive sentences. Provide with necessary cues - stop and return if agitated. *Engage in simple, structured activities that avoid overly demanding tasks Further record review of Resident #2's care plan, created on 07/10/23, indicated a focus of Resident #2 is resistive to care as evidenced by refusing wound care treatments related to dementia. Interventions included: *Encourage as much participation/interaction by the resident as possible during care activities *If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again *Praise when behavior is appropriate Record review of Resident #2's incident report, dated 07/07/23, indicated she was given a cup of coffee on 07/07/23 in the morning in the dining room. She spilled coffee on her left arm and abdomen causing a burn. The incident indicated Resident #2's arm was assessed, cleaned, and silver sulfadiazine cream was applied. A note at the bottom of the incident report indicated Resident #2 spilled coffee on her arm during breakfast causing a burn, and education was provided to the kitchen regarding coffee temperatures. Record review of Resident #2's progress note, dated 07/07/23 at 01:32 PM, written by LVN B, stated: resident was given a cup of coffee this morning in the dining room, resident spilled the coffee on her left arm causing a burn. Treatment nurse, [LVN C], notified and treatment of SSD cream implemented . Record review of Resident #2's progress note, dated 07/09/23 at 05:26 PM, written by LVN B, stated: during rounds this shift it was observed that resident has two burns to left side of abdomen. Area was cleaned with NS and SSD cream applied and covered with dry dressing. Wound care nurse notified and orders put in . Record review of Resident #2's progress note, dated 07/11/23 at 07:18 PM, written by LVN C, stated: Resident evaluated this AM by [Wound care doctor E]. Following wound evaluated: -[left] arm and [left upper quadrant abdomen]: burn to area, 11x10x0.1 cm, 110.00 cm^2, light serous drainage, 80% granulation tissue/20% skin. [treatment] of silver sulfadiazine and rolled gauze daily . Record review of Resident #2's skin evaluation, dated 07/07/23 at 09:05 AM, indicated Resident #2 had a burn to her left upper arm, forearm, antecubital area (the region of the arm in front of the elbow), and forearm. Record review of Resident #2's initial wound evaluation and management summary, dated 07/11/23, indicated she had a burn wound to her left arm that was a full thickness burn (third-degree burn). The wound size was 11 x 10 x 0.1 cm, and the surface area was 110.00 cm^2. The summary further stated: During today's visit, 35 minutes were spent in providing patient care related to reviewing of history, relevant investigations, performing examination, and/or coordination of care and counseling specific to Burn wound of the Left Arm . The summary did not address the burn of Resident #2's abdomen. The exam portion of the summary indicated Resident #2's abdomen was normal, and that there was a wound present to Resident #2's left upper extremity. Record review of Resident #2's wound evaluation and management summary, dated 07/18/23, indicated she had a burn wound to her left arm. The wound size was 10 x 5 x 0.1cm, and the surface area was 50.00 cm^2. The exam portion of the summary indicated Resident #2's abdomen was normal, and that there was a wound present to Resident #2's left upper extremity. The summary did not address the burn of Resident #2's abdomen. Record review of Resident #2's wound care progress note, with a date of service of 07/18/23, and signed by Wound Care Doctor E on 07/20/23 at 3:17PM stated: The patient has partial second degree burns on the abdomen as well. However, the wounds are not open. We will apply Silvadene to wounds with dry dressing daily and prn. Record review of Resident #2's skin ulcer non-pressure assessment, dated 07/11/23 and completed by LVN C, indicated Resident #2 had a burn to her left arm and left lateral (of or relating to the side) abdomen. The onset date was 07/07/23. The size was 11x10 cm. The burn was described as a full thickness wound. The wound was noted to have a small amount of serous exudate (a clear fluid that leaks out of wounds). Record Review of Resident #2's wound care progress note, dated 7/11/23, and signed by Wound Care Doctor E on 09/13/23 at 10:05 AM, indicated that the wound care note dated for 07/18/23 concerning Resident #2's abdominal wound progress note was supposed to be dated for the 7/11/23 visit. This record was provided by the Administrator via email to this surveyor on 09/13/23 at 12:49 PM. Wound Care Doctor E signed this note on 09/13/23 at 10:05 AM, after surveyor interview with the Wound Care Doctor E, and after this surveyor notified the Administrator and DON of IJ on 09/12/23. During an interview on 09/12/23 at 9:40 AM, LVN B said she looked at the burn on Resident #2's left arm and grabbed the wound care nurse, LVN C. She said they immediately rinsed it with water and the wound nurse treated and bandaged the burn. She said she spoke with the kitchen about not giving out hot coffee. She said the resident had not had coffee before and she was unsure if it was given because she asked or if the kitchen had mistakenly given it to her. She said she notified the MD, DON, and family. During an interview on 09/12/23 at 9:55AM, LVN B said she did not notice the burn to Resident #2's abdomen on 07/07/23. During an interview on 09/12/23 at 10:05AM, LVN C said Resident #2 had sustained a coffee burn. He said he did not notice the burn to her abdomen on 07/07/23. He said the abdominal burn was found sometime between 07/07/23 and 07/11/23 because he remembered telling Wound Care Doctor E to look at both wounds on 07/11/23. During an interview on 09/12/23 at 10:19AM, LVN B said she found Resident #2's abdominal burn on 7/9/23. She said she was not told in report about the burns and treated them as new. She thought they were delayed from the coffee burn on her arm on 7/7/23. She said she immediately cleaned and treated the wound, and notified the DON, MD, Family, and treatment nurse. During an interview on 09/12/23 at 10:30AM, the Dietary Manager said they did not log the coffee temperature before the burn incident on the morning of 07/07/23. She said before the incident she expected the aides to read the temperature reading on the coffee maker and not to serve if the coffee temperature was greater than 180 degrees F. She said the dietician gave her some guidance at the time of the event that indicated there was no minimum or maximum that the coffee should be served. She said in the mornings the dietary aides assisted the nursing staff to give out coffee before breakfast. She after the burn incident they changed to use a thermometer to check the temps of the coffee and keep a log. She said the residents also now have coffee cups with lids to reduce the risk of spillage. She said the coffee maker was set to 200 degrees F and the coffee was usually around 180 degrees F when it finished brewing. During an interview on 09/12/23 at 10:40AM, the DON said they do not have a policy that addresses the coffee temperature or the temperature that would be safe to serve to residents. She said after the incident the dietician provided some guidance that they now follow. During an interview on 09/12/23 at 10:51AM, LVN D said she was called into the shower room and noticed the burn on Resident #2's L Arm. She did not observe an abdomen burn on 07/07/23. She treated and covered the wound as ordered by the wound care doctor. She notified the MD, nurse, and DON. She was not sure if Resident #2 normally drank coffee. During an interview on 09/12/23 at 11:28AM, LVN B said he was unsure if Wound Care Doctor E saw the burn to Resident #2's abdomen on the 11th. He said he was not sure if Wound Care Doctor E was going to look at the abdominal wound or not. He said sometimes Wound Care Doctor E does not look at wounds the facility can treat. During an interview on 09/12/23 at 11:35AM, the DON said she expected Wound Care Doctor E to assess and treat the abdominal wound on 7/11/23. During an interview on 09/12/23 at 11:37AM, Wound Care Doctor E said Resident #2 had a big burn wound on her left arm and it never appeared to be infected. He said he was unsure if he saw the abdominal part of the wound on 7/11/23. He said he knew he saw it on the 7/18/23 visit. During an interview on 09/12/23 at 12:50PM, the DON said her investigation showed that Resident #2 spilled coffee on herself during breakfast. The CNA first noticed the burn to Resident #2's left arm when undressing her for a shower after breakfast. She said the CNA noticed the burn approximately at 9 to 9:30 AM. She said the resident did not express pain or any facial grimace. During an interview on 09/12/23 at 12:56PM, the Dietary Manager said they started the coffee temperature log the day after the burn incident. She said it was possible she put the coffee temps for the 8th on the 7th line. She said she did not have a record of the coffee temperature for the morning of the 7th. She said coffee was normally served between 6:30-7AM and breakfast was normally served at 7:15AM. During an interview on 09/12/23 at 3:46PM, CNA F said she took care of Resident #2 on 07/07/23. She said the resident had breakfast in the dining room and then participated in an activity. She said after the activity she took her out of the dining room to bathe her at approximately 10:00 AM. She said she noticed Resident #2's jacket was wet and undressed her. She then noticed a reddened area to Resident #2's left arm. She said she did not remember if Resident #2 had any reddened areas on her abdomen. She said she notified the nurse about the reddened area. During an interview on 09/13/23 at 3:50PM, the ADON said she expected the 400-hall alarm to be turned on at all times. The risk to Resident #1 was that he could have gotten hurt or injured. She expected the nurses to follow the elopement policy. During an interview on 09/13/23 at 3:59 PM, the DON said the risk to her Resident #2 as a result of the abdominal burn not being identified for two days was that she could have had skin breakdown or an infection. She said she expected the nurses to complete a new elopement evaluation when they noticed Resident #1 had new exit-seeking behaviors. She said she expected the 400-hall alarm to be turned on at all times. She said the risk to Resident #1 eloping could have been serious injury. Record review of the facility's policy titled elopement / unsafe wandering, last revised on January 2022, stated: .It is the policy of this facility to provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement . .Procedure 1. Resident with capabilities of ambulation and/or mobility in wheelchair will have an elopement/wandering evaluation completed to determine risks for elopement and unsafe wandering on admission and with observed behaviors of wandering or attempting to elope. 2. Residents with high risk factors will be identified as at risk and will have an individualized care plan developed that included measurable objectives and timeframes. a. Care plan interventions will consider the elements of the evaluation or behavior observations that identified the resident at risk. b. interventions will address the individualized level of supervision needed to prevent elopement/unsafe wandering. 3. Staff shall promptly report any resident who is trying to leave the premises or is suspected of being missing to the Charge Nurse or Supervisor to evaluate the need for further interventions Record review of an undated coffee safety Inservice sheet, provided by the DM on 09/12/23 at 10:39AM stated: .*Coffee should be brewed around 180 degrees F per the manufacturer's recommendation for flavor. *There is no temperature minimum or maximum for point of service. *Temperature designation at point of service is not recommended. *Coffee service below 150 degrees F will likely result in complaints of cold coffee and will not eliminate the risk of burns. *To help mitigate the risk of burns, ensure adequate monitoring and assistance is available to residents Record review of the facility policy for accident intervention, last revised May 2007, stated: .It is the policy of this facility that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents . .Procedures: 1. Assess resident fully. 2. Provide needed emergency care . .3. Notify physician immediately and responsible party by telephone. 4. Minor injuries may be reported to physician and responsible party at the earliest appropriate hour. 5. Document - notification of physician and orders received notification of family incident report - complete nurses notes 6. Follow up - assess resident during each shift - at least once. Document findings for seventy-two (72) hours 7. Report- 24 hours report. Pass information on in shift report The Administrator was notified of an IJ on 09/12/23 at 2:06PM and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 09/13/23 at 11:00AM and included the following: [Facility Name] F689 Plan of Removal 09/12/23 Per the information provided in the IJ Template given on 09/12/23 at 1409, the facility failed to temp the coffee prior to giving it to the residents and failed to assess resident abdomen immediately. The facility failed to have a policy to ensure coffee temps were at the appropriate temperature. The facility failed to follow the elopement policy and the facility failed to ensure the alarm on the exit door on hall 400 was turned on. 1. The Medical Director was notified of IJ on 09/12/23 1425. 2. Skin sweep of total census initiated 09/12/23 and will be completed 09/12/23 by Clinical Resources, Clinical Leaders, MDS Nurse, ADON and DON. 3. Review completed by DON on 09/12/23 of all residents with incidents/accidents in last 30 days to assure adequate assessments were completed. 4. Education initiated with Nurses by DON on assessment of residents post incident/accident/injury. Completion date 9/12/23 at 1800. 5. The DON and Clinical [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure that residents with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 5 residents reviewed for pressure ulcers. (Resident #52) *The facility failed to prevent the sacral wound from deterioration from a Stage 2 to a Stage 4 (over a 7-day period) of time. *The facility failed to notify the physician of the wound decline between the visits on 10/04/22 and 10/11/22. *The facility failed to obtain #52's recommended lab orders (WBC, ESR, and CRP) from the wound care consultant on 11/01/22. *The facility failed to ensure Resident #52's low air loss mattress was functioning for 5 hours and 47 minutes on 11/06/22 from 9:15 a.m. to 3:02 p.m. *The facility failed to provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . *The facility failed to provide #52's wound care consultant evaluation for the sacral wound, indicated on 08/26/22 admission assessment until 9/27/22. An Immediate Jeopardy (IJ) situation was identified on 11/07/22 at 4:40 p.m. While the IJ was removed on 11/08/22, the facility remained out of compliance at the severity of actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents with skin breakdown at risk of pain, worsening of wounds, wound infection, emotional distress, harm, or even death. Findings included: Record review of Resident #52's face sheet with a printed date of 11/07/22, indicated she was a [AGE] year-old-female, admitted on [DATE] and readmitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #52's hospital assessment indicated she admitted to the local hospital on 9/11/22. Record review of an Initial Admission Record dated 08/26/22 indicated Resident #52 was admitted with a weight of 225.4 pounds and was 65 inches tall. The assessment indicated Resident #52's skin was normal, pale, not flushed or blueish colored, warm and not cold. The admission assessment indicated Resident #52 had a 1/2 inch stage 2 ulcer on her left buttock. The additional documentation indicated Resident #52 had non-blanchable open area to the sacrum that was to be evaluated by the wound consultant. The admission record indicated Resident #52 was not provided an alternating air mattress, or a pressure re-distributing overlay mattress. Record review of an Admission MDS dated [DATE] indicated Resident #52 was admitted from an acute hospital, was rarely understood, and rarely understands. The MDS indicated Resident #52's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident #52 did not reject care. The MDS indicated Resident #52 required extensive assistance with two staff for bed mobility, dressing and toilet use. She required limited assistance of two staff with transfers. Resident #52 required extensive assistance with eating and personal hygiene and total assistance of two staff for bathing. The MDS indicated Resident #52 was always incontinent of bowel and bladder. The MDS indicate Resident #52 was 65 inches tall and her weight was 225 pounds. The MDS indicated she had no weight loss of the last month. Section M of the MDS indicated Resident #52 had a pressure ulcer, a formal assessment tool, and a clinical assessment. The MDS indicated Resident #52 was at risk for pressure ulcers. The MDS indicated she had one or more unhealed pressure ulcers. The MDS indicated Resident #52 had a Stage 2 pressure ulcer (some of the outer surface of the skin or the deeper layer was damaged). The MDS indicated Resident #52 did not have any other pressure injuries. Record review of a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the September 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of a Braden Scale for Predicting Pressure Sore Risk dated 08/30/22 indicated Resident #52's score was a 7 indicating very high risk to develop a pressure sore. Record review of a Braden Scale for Predicting Pressure Sore Risk dated 09/06/22 indicated Resident #52's score was a 9 indicating she was at a very high risk to develop a pressure sore. Record review of a hospital History and Physical dated 09/11/22 indicated Resident #52 was admitted and assessed by the physician on 09/11/22 and noted to have a sacral pressure ulcer, and excoriations (removal of skin) in the perineum ( area between anus and vulva) and thigh suggestive of incontinence associated [CONDITION(S)] (diaper rash like). The History and Physical indicated a wound consult recommendation. Record review of an Initial Admission assessment dated [DATE] indicated Resident #52 was readmitted after a hospital stay for [MEDICATION(S)] (bladder infection). Resident #52 was 65 inches tall, and her weight was 220.8 pounds. The admission assessment indicated Resident #52 did not have a pressure re-distributing mattress but had an alternating air mattress. The general skin condition of Resident #52 was indicated to be normal and warm. The skin integrity indicated she had moisture associated skin damage on her buttocks but no pressure ulcers. Record review of the EMR (electronic medical record) dated October 2022 indicated Resident #52 was ordered a low air loss mattress initiated on 09/26/22. Record review of a skin evaluation dated 09/27/22 indicated Resident #52 had MASD (moisture associated skin damage) to her buttocks completed by the treatment nurse . The note did not reflect a pressure injury. Record review of an Initial Wound Evaluation and Management Summary (documented by the wound care consulting physician) dated 9/27/22 indicated Resident #52 had a Stage 2 pressure ulcer to the sacrum for at least 1 day duration. The note indicated there was moderate serous exudate (thin watery drainage). The note indicated the wound to Resident #52's sacral region measured 7 cm x 8 cm x 0.1 cm with moderate exudate. The treatment plan included to apply calcium alginate once daily for 30 days and collagen powder once daily for 30 days and cover with a gauze sponge once daily. The note indicated a recommendation for a Prealbumin (protein monitoring) and a hemoglobin AIC (blood sugar monitoring). Record review of a facility wound care report dated October 2022 indicated Resident #52 had a pressure ulcer to her sacrum (a shield shaped bony structure located at the base of the lumbar vertebrae and that was connected to the pelvis). The facility wound report indicated Resident #52's pressure wound was obtained in-house on 9/27/22. The wound stage was classified as unstageable due to slough and eschar. Resident #52 was high risk due to the results of the last Braden score completed on 09/12/22. The wound care report indicated in the month of October 2022 Resident #52's sacral wound reflected the following: Week #1 measured 6 cm x7.0 cm 0.1 cm; Week #2 measuring 6 cm x 5 cm x 1 cm; Week #3 measuring 6 cm x 9 cm x 1.4 cm; Week #4 measuring 10 cm x 12 cm x 2 cm; and week #5 measuring 10 cm x 12 cm x 5 cm. Record review of a Wound Evaluation and Management Summary dated 10/04/22 indicated Resident #52 had a stage 2 pressure ulcer to her sacrum for at least 7 days. The note indicated the wound had moderate serous exudate. The wound measurements were 6 cm x 7 cm x 0.1 cm with moderate exudate and 10% skin. The treatment plan included collagen powder application once daily, calcium alginate application once daily cover with gauze sponge once daily. Record review of a Wound Evaluation and Management Summary dated 10/11/22 indicated Resident #52 now had an unstageable wound due to necrosis (dead) tissue to her sacrum. The note indicated there was moderate serous exudate and was now a full thickness wound (tissue loss of the epidermis and dermis). The note indicated Resident #52's wound measured 6 cm x 9.5 cm x 1 cm. The note indicated the wound had 40% slough, 50% granulation tissue, and 10% skin with the deteriorated wound status. The wound was surgically debrided (removal of dead tissue with a blade) devitalized tissue including slough, biofilm, and non-viable tissue at a depth of 1 cm. The treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the progress notes from 10/04/22 through 10/11/22 did not reflect a decline in Resident #52's sacral wound from a Stage 2 to a Stage 4 during this time nor any documentation of the notification of her physician or responsible party. Record review of laboratory results dated [DATE] indicated WBC (white blood cells measuring infection) resulted at 15.7 with the normal range of 4.0-9.6, ESR Erythrocyte sedimentation rate of 90 indicated a high level of inflammation. The normal ESR range was 0-20. Record review of a wound culture dated 10/13/22 and resulted on 10/15/22 indicated Resident #52's sacral wound had a moderate gram-positive coccus. The wound had many groups A streptococcus isolated (infections range from minor to illness to very serious and deadly diseases) and moderate proteus mirabilis (can cause serious infections in humans). Record review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Although Resident #52's wound culture was resulted on 10/15/22 the order for the antibiotic therapy was not provided or initiated until 10/18/22 when Resident #52 received two doses). Record review of a Wound Evaluation and Management Summary dated 10/18/22 indicated Resident #52 continued to have an unstageable sacral wound with moderate serous exudate. The note indicated the wound measured 6 cm x 9 cm x 1/4 cm with 30% being slough, 60 % granulation tissue, and 10% skin. The treatment plan was calcium alginate twice daily and a gauze sponge twice daily. The wound was again debrided using a surgical blade. The physician surgically excised devitalized tissue including slough, biofilm, and non-viable subcutaneous level tissues at a depth of 1/4 cm. Record review of a Wound Evaluation and Management Summary dated 10/25/22 indicated Resident #52 had a Stage 4 pressure wound (wound extending to the ligaments, muscle, and bone) with moderate serous exudate. The wound measurements were 10 cm x 12 cm x 2 cm with undermining at 4 cm. The treatment plan was sodium hypochlorite solution and calcium alginate with a second dressing. Record review of a nurse practitioner no te dated 10/31/22 at 9:00 a.m., indicated Resident #52 was currently being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Often cause extreme pain infection, invasive surgeries, or even death). The note indicated she was non-distressed in appearance. The note indicated the NP was increasing her pain medication to [MEDICATION(S)] 100 milligrams by mouth every 6 hours routinely. Record review of a Wound Evaluation and Management Summary dated 11/01/22 indicated Resident #52 had a Stage 4 pressure ulcer to the sacrum. The wound had moderate serous exudate. The wound measurement was 10 cm x 12 cm x 5 cm with undermining of 4 cm at 3 o'clock. The wound had 20% slough and 60% granulation tissue and 20% muscle tissue with the wound deteriorated since last visit. Again, the wound was debrided using a surgical blade. The excision of 24.0 cm^2 squared of devitalized tissue including slough, biofilm and non-viable muscle level tissues were removed at a depth of 5 cm. The physician recommended a CRP (measuring protein in the blood), WBC (lab for white blood cells indicating infection), ESR (lab level of measuring inflammation) and a culture of the sacral wound. Record review of the Resident #52's laboratory results did not indicate laboratory results for the CRP, WBC, and ESR recommended by the wound care physician on 11/01/22. During an interview on 11/07/22 at 12:38 p.m., the DON indicated Resident #52's labs ordered on 11/01/22 was not completed because they were only suggested. The DON indicated she was unsure why the wound culture was obtained and not the laboratory levels. During an interview on 11/07/22 at 1:20 p.m., the wound care consulting physician indicated Resident #52's wound care started with a Stage 2 sacral wound on 9/27/22 which had declined now to a large Stage 4 sacral wound. The physician indicated he had made the recommendation for labs to determine if Resident #52 had [CONDITION(S)] (bone infection). The physician indicated he had not seen bone in the wound and therefore required the labs to help determine if Resident #52 required intravenous antibiotic therapy instead of antibiotics through the gastrostomy tube. During an observation on 11/06/22 at 9:15 a.m., Resident #52's low air loss mattress cord was not plugged in to the electrical outlet. The mattress cord was lying on the floor underneath her bed. The lights on the monitoring box were not on. During an observation on 11/06/2022 at 3:02 p.m., Resident #52's low air loss mattress cord was not plugged in to the electrical outlet. The mattress cord was lying on the floor underneath her bed. The lights on the monitoring box were not on. During an observation on 11/07/22 at 7:50 a.m., Resident #52's low air loss mattress was now plugged into the electrical outlet and the lights were on the monitor box. Resident #52 was facing the right side toward the wall. Resident #52 had a scabbed area to her left [NAME] (ear). Record review of a comprehensive care plan indicated Resident #52 had a pressure ulcer to sacral area initiated on 10/14/22 with a revision on 11/07/2022 there was no goal for the pressure wound. The interventions included pressure relieving devices per orders, wound consultant visits, and weekly had to toe skin at risk assessments. A potential for pressure ulcer development care plan indicated the goal was to have intact skin, free of redness, blisters, or discoloration with the interventions of administer treatments as ordered and monitor the effectiveness, notify the nurse immediately of any new areas of skin breakdown such as redness, blisters, bruises, discoloration noted during bathing or daily care, obtain and monitor lab and diagnostic work reporting results to the medical director, and weekly head to toe skin at risk assessments. Record review of a wound culture dated 11/04/22 and resulted on 11/06/22 indicated Resident #52 continued to have a sacral wound infection with proteus mirabilis and moderate group A streptococcus. The physician ordered to complete the oral antibiotic [MEDICATION(S)]. Record Review of a November 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #52's clinical record indicated the CRP, WBC, ESR, was not obtained until after surveyor intervention on 11/07/22. The WBC, CRP, ESR, and a wound culture were recommended on the 11/01/22 wound consultant report. The records indicated the wound care consultant physician obtained Resident #52's wound culture was obtained during the wound care. The WBC count was 10.3 with the normal level of 4.0 - 9.6. The CRP result was high at 25.9 indicating inflammation the normal range was 0.1 - 0.8. The ESR result was high indicating inflammation at a result of 109 with the normal range of 0-20. Record review of a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #52 received her first dose on 11/08/22 at 4:00 a.m. Record review of Resident #52's consolidated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] tablet 500-125mg administer 1 tablet via the gastrostomy every 12 hours for wound infection initiated on 11/05/22 with an end date of 11/12/22 for a wound infection. Dakin's (1/4 strength) Solution 0.125% (Sodium hypochlorite) apply to sacrum topically every shift for pressure wound. Record review of a care plan dated 11/07/22 indicated Resident #52 was on intravenous antibiotics for [CONDITION(S)] and the goal was not to have any complications. The interventions included to monitor and document any symptoms of infection such as drainage, inflammation, swelling, redness, or warmth. Provide PICC line care every 7 days and flush the PICC line prior to the medication administration was the other interventions for Resident #52. During an observation and interview on 11/07/22 at 9:16 a.m. to 9:49 a.m., the treatment nurse performed wound care for Resident #52's Stage 4 sacral wound. The treatment nurse removed the top dressing and revealed a large and deep sacral wound with necrotic (dead) tissue at the noon to 3'oclock portion of the wound. The dressing was saturated in a copious amount of serosanguineous (blood-tinged drainage), and the wound was odorous. The treatment nurse indicated he was assisted by the staffing coordinator because she had a stronger stomach and could handle the odor. During the wound care Resident #52 began grimacing, groaning, and moving her face to the right imbedding her face in her pillow. Resident #52 was encouraged by the staffing coordinator to squeeze her hand. The staffing coordinator indicated Resident #52 was displaying pain. The staffing coordinator indicated Resident #52 displayed this behavior each time during the actual wound care procedure. The treatment nurse indicated Resident #52 was medicated earlier this morning. The treatment nurse indicated he had even mentioned to the family about hospice care to have more effective pain management. During the wound care neither the treatment nurse nor the staffing coordinator stopped the wound care process to ensure adequate pain relief was achieved prior to finishing the treatment. Resident #52 made a grimacing face as the treatment nurse initiated the cleaning of the wound. The staffing coordinator indicated the cleaning must hurt by the face Resident #52 was making. The treatment nurse stated he was unsure if the moaning was pain or how Resident #52 was positioned. During the repositioning of Resident #52 the surveyor noticed two skin concerns. The treatment nurse indicated he was unaware of these two areas. Resident #52 had a 2.5 cm x 0.5 cm x 0.1 cm stage 2 pressure injury, and a 0.5 cm x 0.5 cm fluid filled blister to the right heel. The treatment nurse indicated Resident #52 should have had some heel protection boots on. During an interview after the wound care the treatment nurse indicated Resident #52's grunting, moaning, and grimacing was demonstration of pain. The treatment nurse indicated he should have stopped the procedure and obtained pain medication. The treatment nurse indicated he did not stop the wound care, assess Resident #52 because he was in a hurry to finish. The treatment nurse indicated even though Resident #52's wound looked bad it was actually better in his opinion. The treatment nurse indicated the antibiotic therapy and the Daiken's wound solution was helping the odor. During a telephone interview on 11/07/22 at 6:32 p.m., the MD indicated he was aware Resident #52 had a Stage 4 pressure injury but had not seen the wound himself. The MD indicated he was not made aware the wound declined in a 7-day period from a Stage 2 to a Stage 4. The MD indicated he had not been made aware Resident #52 had two new wounds today nor had he been informed Resident #52 had increased pain with her wound care. The MD indicated he expected the wound care nurse to stop the wound care when any resident demonstrated pain. The MD indicated a low air mattress being unplugged was not ideal for wound healing. The MD indicated he allowed the wound care physician to make recommendations for the wound needs. During an interview on 11/07/22 at 1:51 p.m., CNA F indicated she was the CNA providing care to Resident #52. CNA F indicated she had not noticed Resident #53's two new wounds on her right heel. During an interview on 11/07/22 at 4:16 p.m., the DON indicated Resident #52 was admitted on a Friday evening. The DON indicated the treatment nurse did not work the weekend and was not made aware of the wound care referral therefore Resident #52 was not seen by the wound care physician, and the DON indicated Resident #52's wound was not open on 08/26/22 therefore the wound care consulting physician wound not have seen Resident #52's wound. The DON indicated Resident #52's wound declined from a Stage 2 to a Stage 4 only after the wound care consultant physician debrided the wound. During a phone interview on 11/08/22 at 6:06 p.m., the wound consultant physician was questioned about the debridement of a stage 2 pressure wound. The wound consultant physician stated he would never debride a Stage 2 wound to any resident. He stated he would debride a Stage 3, Stage 4, or an unstageable pressure ulcer. The wound care physician indicated he had never debrided a Stage 2 wound on Resident #52. Record Review of a Wound Evaluation and Management Summary dated 11/08/22 indicated Resident #52 had a stage 4 pressure wound to the sacrum. There was a light serous drainage. The wound measured 11 cm x 14 cm x 5 cm with undermining at 3 o'clock measuring 4 cm. The wound was 20 % slough, 60% granulation tissue, and 20% muscle with the wound deteriorated. The note included additional wound details of now the wound has [CONDITION(S)] (inflammation of the bone caused by an infection). The physician recommended to start [MEDICATION(S)] (antibiotic) for 4 weeks for a maximum of 8 weeks if indicated. The wound dressing continues to be sodium hypochlorite solution apply twice daily and with a gauze sponge dressing twice daily. The note indicated Resident #52's wound was debrided using a surgical blade excising 30.8 cm^2 squared of devitalized tissue including slough, biofilm, and non-viable muscle tissue was removed at a depth of 5 cm. Record review of a chest x-ray dated 11/08/22 for a PICC (peripherally inserted central catheter) line placement verification. Resident #52 received a PICC Line for the administration of intravenous antibiotic therapy. Record review of a Skin and Wound Monitoring and Management policy and procedure dated 03/2015 and revised date of 01/2022 indicated It was the policy of this facility that 1. A resident who enters the facility without a pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; and 2. A resident having pressure injury (s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. The purpose of this policy was that the facility provides care and services to 1. Promote interventions that prevent pressure injury development; 2. Promote the healing of pressure injuries that are present (including prevention of infection to the extent possible); and 3. Prevent the development of additional, avoidable pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are no visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage. Stage 4 pressure injury: full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury. 7. Communication of Changes a. any changes in the condition of the resident's skin as identified daily, weekly, monthly or otherwise, must be communicated to the resident/responsible party, resident physician, and others as necessary to facilitate healing. The Administrator and DON were notified 11/07/22 at 5:02 p.m. that an Immediate Jeopardy (IJ) was identified due to the above failures. The IJ template was provided on 11/07/22 at 5:05 p.m. The following Plan of Removal submitted by the facility was accepted on 11/08/22 at 8:34 p.m. and included the following: Immediate action: The Medical Director was notified of IJ on 11/7/22 at 5:45pm. Review of all pressure ulcer treatments orders was initiated and will be completed 11/08/22 by the DON. Review/Identification/Interventions will be completed to assure all residents at high risk for pressures ulcers (as determined via Braden scale) will be completed by DON/ADON by 11/07/22. Review of all residents with current pressure ulcers to assure appropriate treatment in place. Education initiated with Nurses and CNAs that included change in condition procedures for wounds, change in behaviors, refusal of care, notification of changes in condition, wound identification, and documentation. This education will be included in the new hire orientation and to including agency staff. Identification of Others Affected Currently there are 67 residents residing in the facility. The facility initiated a skin sweep on 11/07/22 of all residents and will complete 11/08/22. Systemic Change to Prevent Re-occurrence DON started in-service on 11/07/22 with facility charge nurses and CNAs on documentation and monitoring skin integrity system along with skin assessments. The training includes use of shower sheets by the CNAs as well as the Stop and Watch Program, reporting new areas to nurses, nurse documentation / treatment / notification of new areas, new admission assessments to occur once a week for four weeks, quarterly, and with any change of condition. In-services included: documenting skin assessments, timely follow up and notification to RP, DON and MD, wound treatments and reporting until all applicable personnel complete education. In-services will be completed prior to accepting assignments for all charge nurses, nursing assistants, including agency, new hires, and PRN staff. This education will be included in the new hire orientation to include agency - will be completed by 11/08/22. Nurses will complete education for skin assessment prior to the start of their next shift. CNAs will also receive education on shower sheets and Stop and Watch program prior to the start of their shift will be completed by 11/08/22. Shower sheets to be completed by CNA and any new areas to be communicated to Charge Nurse. Skin assessments to be completed by Treatment Nurse, document and communicate any new skin changes to physician, responsible party, and place on 24 hr. report for DON notification. Monitoring: Interviews on 11/08/22 from 12:58 p.m. until 3:18 p.m. the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interviews with 8 CNAs indicated they had received a written in-service regarding monitoring low air loss mattresses for functioning properly, reporting of all new alterations in skin integrity to the licensed nurse immediately upon discover. Utilization of the shower sheets to document and identify all skin alterations found on a resident while providing care. Interviews with 6 LVNs indicated to monitor a low air loss mattress every shift to determine whether functioning properly. Reporting of skin alterations to the physician, DON, and responsible party. A treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The use of shower sheets for monitoring new skin issues. Interviews with 5 RNs indicated to monitor a low air loss mattress every shift to determine whether functioning properly. Reporting of skin alterations to the physician, DON, and responsible party. A treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The use of shower sheets for monitoring new skin issues. During an interview on 11/08/22 at 12:58 p.m., the DON indicated she reviewed all pressure ulcer treatments and did not change any treatments. She said a full skin sweep was completed and all identified skin alteration had a treatment in place even if it was a healing scratch. She in-serviced all staff on change of condition on wounds, change in behaviors, refusal of care, notification of changes, wound identification, and documentation. The DON indicated she in-serviced night shift last night and day shift today and including PRN (as needed) nurses. The DON indicated she in-serviced regarding skin integrity, shower sheets with every shower for CNA's, stop and watch for CNA's (doc anything new or new to that CNA), new admission assessment weekly for 4 weeks, doc skin assessment, timely follow up, notifying the responsible party, MD, and the DON. The in-services included reporting all new treatments to the DON, ADON, and treatment nurse. The DON indicated all staff not having the in-services would be in-serviced prior to accepting assignments. Record review of a written in-service dated 11/07/22 indicated the policy of the facility was if a resident has a low air loss mattress it must be assessed every shift to determine if it is function properly. When in a resident's room and notice a mattress unplugged, first plug it back in and you must report to the nurse. Record review of a written in-service dated 11/07/22 indicated unlicensed staff were required to report all new alterations in skin integrity which includes bruises, skin tears, abrasions, scratches, discolored areas, etc. to licensed nurse immediately upon discovery. Licensed staff were required to report alterations of skin integrity to the physician, DON, and the resident's responsible party. A treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The treatment ordered must be reported to the responsible party and notification must be documented. Record review of a written in-service dated 11/07/22 indicated the unlicensed staff would utilize shower sheets to document and identify all skin alterations found on a resident at any point while providing care. The shower sheet must be turned into the treatment nurse at the end of the shift, with signatures of the nurse indicating understanding of alterations and copy of new order received from the physician. The Administrator and DON were informed the Immediate Jeopardy was removed on 11/08/22 at 8:34 a.m. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure pain management is provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 20 residents reviewed for pain management. (Resident #52) The facility failed to ensure Resident #52 had effective pain management by evaluating Resident #52's by prior to wound care, during wound care, and post wound care. The facility failed to acknowledge or provide any pain relief medications for Resident #52's pain when she was grimacing and groaning during wound care. The facility failed to notify the physician of Resident #52's pain with wound care. These failures could place residents who received wound care, who had chronic pain conditions, who received as needed pain medication, or who received routine pain medications at risk for not having had their pain addressed causing undo suffering. An Immediate Jeopardy (IJ) situation was identified on 11/07/22 at 4:40 p.m. While the IJ was removed on 11/08/22, the facility remained out of compliance at the severity of actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: Record review of Resident #52's face sheet with a printed date of 11/07/22, indicated she was a [AGE] year-old-female, admitted on [DATE] and readmitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of an Initial Admission Record dated 08/26/22 indicated Resident #52 was admitted with a weight of 225.4 pounds and was 65 inches tall. The admission record indicated Resident #52 was not provided an alternating air mattress, or a pressure re-distributing overlay mattress. The assessment indicated Resident #52's skin was normal, pale, not flushed or blueish colored, warm and not cold. The admission assessment indicated Resident #52 had a 1/2 inch stage 2 ulcer on her left buttock. The additional documentation indicated Resident #52 had non-blanchable open area to the sacrum that was to be evaluated by the wound consultant. The assessment indicated Resident #52 smiles occasionally and was very quiet, indicating Resident #52's baseline. Record review of an Admission MDS dated [DATE] indicated Resident #52 was admitted from an acute hospital, was rarely understood, and rarely understands. The MDS indicated Resident #52's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident #52 did not reject care. The MDS indicated Resident #52 required extensive assistance with two staff for bed mobility, dressing and toilet use. She required limited assistance of two staff with transfers. Resident #52 required extensive assistance with eating and personal hygiene and total assistance of two staff for bathing. The MDS indicated Resident #52 was always incontinent of bowel and bladder. The MDS indicated in the section J0100 Pain Management Resident #52 received no scheduled pain medications, received no as needed pain medication, nor any non-medication pain interventions. The MDS indicate Resident #52 was 65 inches tall and her weight was 225 pounds. Section M of the MDS indicated Resident #52 had a pressure ulcer, a formal assessment tool, and a clinical assessment. The MDS indicated Resident #52 was at risk for pressure ulcers. Section M0210 indicated had one or more unhealed pressure ulcers. The MDS indicated in Section M0300 Resident #52 had a Stage 2 pressure ulcer (some of the outer surface of the skin or the deeper layer was damaged). The MDS indicated Resident #52 did not have any other pressure injuries. The MDS did not reflect a pain assessment. The comprehensive care plan dated 8/26/22 with a revision on 11/07/22 indicated Resident #52 had a potential for pain with a goal of Resident #52 would voice a level of comfort or will not have an interruption in normal activities due to pain. The interventions included to administer analgesia medication as per orders; give 1/2 hour before treatments or care, anticipate need for pain relief and respond immediately to any complaint of pain, monitor, and document any side effects, monitor and report any symptoms of non-verbal pain, changes in breathing, grunting, moaning, and even silence. Also report grimacing, clenched teeth, tense body, and face appearing worried. Pain assessment each shift and observe and report any changes in normal routine. Record review of the October 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication record indicated Resident #52 received only 8 doses in the month of October. Record review of the October 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the November 2022 consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This medication was on scheduled for administration at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. Resident #52 was ordered Acetaminophen 325 mg 2 tablets every 4 hours as needed for pain/temperature. Record review of the October 2022 electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The record indicated Resident #52 had acetaminophen 325 mg give 2 tablet every 4 hours as need for pain ordered on 9/12/22. The record indicated Resident #52 received acetaminophen administration a total of 4 times in the entire month of October. Record review of the November 2022 electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The record indicated Resident #52 received acetaminophen 325 mg 2 tablets every 4 hours on 11/05/22. The electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the November 2022 electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 11/04 /22 rated at a 2; 11/05/22 rated at a 6, 11/06/22 rated at a 2 on the day shift and a 3 on the night shift, and 11/07/22 pain at a 3 on the day shift. The November EMAR indicated Resident #52 received [MEDICATION(S)] 100 mg by gastrostomy tube four times daily 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. The EMAR indicated Resident #52 had acetaminophen 325 mg two tablets administered on 11/5/22 for a pain level of a 6. The EMAR indicated the medication was effective. During an observation and interview on 11/7/22 at 9:16 a.m. to 9:49 a.m., the treatment nurse performed wound care on Resident #52's Stage 4 sacral wound. The treatment nurse removed the top dressing and revealed a large and deep sacral wound with necrotic (dead) tissue at the noon to 3'oclock portion of the wound. The dressing was saturated in a copious amount of serosanguineous (blood-tinged drainage), and the wound was odorous. The treatment nurse indicated he was assisted by the staffing coordinator because she had a stronger stomach and could handle the odor. During the wound care Resident #52 began grimacing, groaning, and moving her face to the right imbedding her face in her pillow. Resident #52 was encouraged by the staffing coordinator to squeeze her hand. The staffing coordinator indicated Resident #52 was displaying pain. The staffing coordinator indicated Resident #52 displayed this behavior each time during the actual wound care procedure. The treatment nurse indicated Resident #52 was medicated earlier this morning. The treatment nurse indicated he had even mentioned to the family about hospice care to have more effective pain management. During the wound care neither the treatment nurse nor the staffing coordinator stopped the wound care process to ensure adequate pain relief was achieved prior to finishing the treatment. Resident #52 was noted to be making a grimacing face as the treatment nurse initiated the cleaning of the wound. The staffing coordinator indicated the cleaning must hurt by the face Resident #52 was making. The treatment nurse stated he was unsure if the moaning was pain or how Resident #52 was positioned. During the repositioning of Resident #52 the surveyor noticed two skin concerns. The treatment nurse indicated he was unaware of these two areas. Resident #52 had a 2.5 cm x 0.5 cm x 0.1 cm stage 2 pressure injury, and a 0.5 cm x 0.5 cm fluid filled blister to the right heel. The treatment nurse indicated Resident #52 should have had some heel protection boots on. During an interview after the wound care the treatment nurse indicated Resident #52's grunting, moaning, and grimacing was demonstration of pain. The treatment nurse indicated he should have stopped the procedure and obtained pain medication. The treatment nurse indicated he did not stop the wound care, assess Resident #52 because he was in a hurry to finish. During an interview on 11/07/22 at 12:17 p.m., the nurse practitioner indicated she had not actually visualized the Stage 4 pressure ulcer to Resident #52's sacrum. She indicated she ordered the [MEDICATION(S)] in anticipation the wound would cause discomfort and she indicated she had not been advised the pain medication was not effective. The nurse practitioner also indicated she expected the nursing staff to monitor and notify her of ineffective pain management. The Nurse Practitioner indicated she expected the pain medication to be administered 1-2 hours prior to wound care. During an interview on 11/07/22 at 12:46 p.m., LVN E indicated she had been completing the wound care for Resident #52 and had noticed the facial grimacing and some moaning . LVN E indicated she had notified the nurse practitioner of the pain and the [MEDICATION(S)] order was provided. During an interview on 11/07/22 at 1:20 p.m., the wound care consulting physician indicated Resident #52 had a rather large Stage 4 sacral wound. The physician indicated he had made the recommendation for labs to determine if Resident #52 had [CONDITION(S)] (bone infection). The physician indicated he had not seen bone in the wound and therefore required the labs to help determine if Resident #52 required intravenous antibiotic therapy instead of antibiotics through the gastrostomy tube. The wound care consultant indicated Resident #52 had not displayed pain during his wound care, but he had used a topical anesthesia with wound debridement. During a telephone interview on 11/07/22 at 6:32 p.m., the MD indicated he was aware Resident #52 had a Stage 4 pressure injury but had not seen the wound himself. The MD indicated he had not been made aware Resident #52 had two new wounds today nor had he been informed Resident #53 had increased pain with her wound care. The MD indicated he expected the wound care nurse to stop the wound care when any resident demonstrated pain. During an interview on 11/08/22 at 1:15 p.m., the treatment nurse indicated he should have premedicated Resident #52 prior to the wound care on 11/07/22. The treatment nurse indicated he should have then waited for the medication to be effective prior to starting the wound care for Resident #52. The treatment nurse indicated the PAINAID tool was used to indicated pain for non-verbal residents. During an interview on 11/08/22 at 5:25 p.m., the DON indicated Resident #52 had been medicated two hours prior to her treatment and this was in the time frame of an effective pain management criteria. Record review of a pain policy dated 05/2007 with a revision on 01/2022 indicated the policy of this facility to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Purpose Identify circumstances when pain can be anticipated. Procedure 3. For the resident who was unable to communicate verbally or understand abstract concepts, the PAINAD scale for the cognitively impaired will be used and documented in the residents HER. . The Administrator and DON were notified on 11/07/22 at 5:02 p.m. an Immediate Jeopardy (IJ) was identified due to the above failures. The IJ template was provided on 11/07/22 at 5:05 p.m. The following Plan of Removal submitted by the facility was accepted on 11/08/22 at 8:34 p.m. and included the following: Immediate action: Immediate Action The Medical Director was notified of IJ on 11/7/22 at 5:45pm. Review of all residents with pressure ulcers to assure current orders are in place for pain management to be completed by DON by 11/07/22 Education provided to all licensed nurses to assure pain assessment is completed prior to all wound care. New pain medication orders received for affected resident from physician for [MEDICATION(S)] 5mg/5ml - give 5 ml via gastrostomy tube daily for pain. [MEDICATION(S)] 100mg via gastrostomy tube Q 6 as needed for pain and Tylenol 500mg 2 tabs via gastrostomy tube every 8 hours as need for pain. Identification of Others Affected Currently there are 67 residents residing in the facility. The facility will assure pain assessments for all residents with pressure ulcers are completed prior to treatment. Systemic Change to Prevent Re-occurrence DON started in-service on 11/07/22 with facility charge nurses on documentation and pain assessments prior to wound care treatments. The training includes use of pain assessment prior to any wound care and post pain assessment after treatment is completed will be completed by 11/08/22. Nurses will complete education for pain assessment prior to the start of their next shift - date of completion 11/08/22. Education provided to charge nurses to notify physician if pain management plan is ineffective based on assessment of the resident. Monitoring: Interviews on 11/08/22 from 12:58 p.m. until 3:18 p.m. the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interviews with 8 CNAs indicated they had received a written in-service regarding monitoring reporting pain to the nurses. Referencing pain is whatever the person says it is, existing whenever the experiencing person say it does. Also referencing, Pain is an unpleasant sensory and emotional experience, associated with, or potential tissue damage. Pain is an unpleasant sensory and emotional experience, associated with actual or potential tissue damage. Interviews with 6 LVNs indicated the in-services included: *Pain assessment was a broad concept involving clinical judgement based on observation of the type, significance, and context of an individual's pain experience. *Provide analgesia 30 to 60 minutes before dressing change. Assess the patient for pain before, during, and after dressing changes. *If no order available for analgesia please notify physician prior to performing the treatment. *Pain assessment to be documented in the resident's medical record, before, during, and after the dressing changes. Interviews with 5 RNs indicated the in-services included: *Pain assessment was a broad concept involving clinical judgement based on observation of the type, significance, and context of an individual's pain experience. *Provide analgesia 30 to 60 minutes before dressing change. Assess the patient for pain before, during, and after dressing changes. *If no order available for analgesia please notify physician prior to performing the treatment. *Pain assessment to be documented in the resident's medical record, before, during, and after the dressing changes. During an interview on 11/08/22 at 12:58 p.m., the DON indicated the nursing staff would be in-serviced prior to accepting their assignments regarding pain. The DON indicated the nurse would assess pain prior, during, and after wound care or ADL care. The DON indicated the nurses will notify the physician if there were no analgesics to administer for pain needs. During an interview on 11/08/22 at 4:41 p.m., the Administrator indicated he was under the understanding the facility had done all the appropriate interventions regarding Resident #52's Stage 4 pressure ulcer. The administrator indicated he expected the residents to have their pain managed. The Administrator indicated education had been provided to the staff and the skin and pain issues will be taken to on-going scheduled QAPI meetings. The Administrator and DON were informed the Immediate Jeopardy was removed on 11/08/22 at 8:34 a.m. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.