Every finding on record at Legend Oaks Healthcare and Rehabilitation - West S

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident #1) out of 6 residents reviewed for dignity. The facility failed to comply with Resident #1's request not to have CNA G assigned to her care and to not enter her room. This failure could place residents at risk of diminished dignity and affect their quality of life.The findings included: Record review of Resident #1's admission Record, dated 06/11/2026, revealed an [AGE] year-old female admitted [DATE] and re-admitted [DATE]. Resident #1 was listed as her own responsible party. Record review of Resident #1's Medical Diagnoses, undated and accessed 06/11/2026 at 3:54 p.m., revealed diagnoses including heart failure (chronic condition where the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), hypertension (condition where the force of blood against the artery walls is consistently too high), acute kidney failure (kidneys suddenly stop working), Transient Ischemic Attack (TIA) (temporary blockage of blood flow to the brain), anxiety disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #1's quarterly MDS assessment, dated 06/01/2026 and signed 06/14/2026 as completed, reflected a BIMS score of 15 indicating cognition intact. Resident #1 was documented as having not exhibited any behavioral symptoms. Resident #1 was documented as requiring incontinence care. Resident #1's functional abilities were documented as requiring dependent to set up or clean-up assistance and requiring a wheelchair for mobility. Record review of Resident #1's care plan, undated and accessed 06/11/2026 at 4:24 p.m., revealed, . [Resident #1] has bladder incontinence r/t [related to] Impaired Mobility and goal . [Resident #1] Will remain free from skin breakdown due to incontinence and brief use through the review date. and interventions .BRIEF USE: uses disposable briefs. Change q 2-3 hrs. [every 2 to 3 hours] and prn [as needed] . INCONTINENT: Check as required for incontinence. Wash, rinse and dry perineum. date initiated 05/08/2024 and revised on 10/29/2024. Record review of Resident #1's progress notes, dated 04/10/2026 (CNA G's date of hire) to 06/11/2026 (EMR access date) revealed no progress notes were found mentioning Resident #1's reported incident or preferences regarding CNA G and the request to not have him provide her with direct care. Record review of Resident #1's EMR Misc. tab on 06/11/2026 did not reveal documentation of NF Incident Report or Grievance Request. During an observation and interview on 06/10/2026 at 2:11 p.m. Resident #1 was noted to be sitting in her wheelchair outside of her room socializing with a male resident. She was dressed well, groomed appropriately and had no odors. Resident #1 had clear thinking and reasoning, she was able to communicate fluently, express thoughts clearly, and understand others. She was aware of time, place, and person, without disorientation. Resident #1 stated that she does not have a preference in gender of staff to provide care, but she does not like one male aide due to an incident that occurred less than one month back. She stated a male aide (name unknown) and described as tall, Columbian, who usually works evenings was providing her with incontinence care and he saw chocolates on her bedside table and told her she was eating too many chocolates and that was why she was fat. She stated the incident was reported to NF staff, but the same male aide was on shift last night (06/09/2026) and he tried to provide her with incontinence care after she used the call light for assistance. She stated he does not know how to provide care. She stated she was a retired RN, and she was a Director of Nursing for 18 years and you do not talk to residents in this manner. Resident #1 revealed that she reported the incident to the NF staff immediately after it occurred. She stated she has notified NF staff several times and the ADON A that she does not want this male aide in her room providing her with care. Said stated she does not trust this male aide and she held her bowels overnight to avoid receiving care from him. During an interview on 06/11/2026 at 12:00 p.m. the Wound Care Nurse stated staff were expected to report ANE immediately to Administrator who was the Abuse Coordinator. She stated if she were to witness staff being inappropriate, rude, or talking to residents disrespectfully she would report it immediately. She stated all grievances or complaints should be reported to the charge nurse and the Social Worker for follow-up. During an interview on 06/11/2026 at 1:30 p.m., CNA B revealed she was knowledgeable of ANE and resident rights and provided examples. She stated she was to report ANE immediately to the Administrator. CNA B stated if she were to witness or hear staff being rude or disrespectful to a resident, she would report this behavior immediately and stated that this could impact a resident and make them fearful of staff if left unreported. During an interview on 06/11/2026 at 2:53 p.m., CNA C revealed she was knowledgeable of ANE and resident rights and provided examples. She stated she was to report ANE immediately to the Administrator. She stated violations of ANE, and resident rights of a resident could cause them to become depressed, sad, not want to engage in activities, or refuse to eat. CNA C stated she was familiar with Resident #1's care, she requires incontinence care, requires person assist, cognition was intact and she can express her needs and wants. She recalled that the previous week Resident #1 reported to her that she did not trust an overnight aide (name unknown). She stated an incident occurred, but she was not provided with details, but that she had already reported it to the charge nurse on shift the day of the incident and LVN D. She stated that Resident #1 notified her that the incident had already been reported and the male aide (name unknown) was not allowed back in her room and she did not believe it had to be reported further. She stated she did not recall the name of the male aide, but she did recall he was new and he worked overnight. During an interview on 06/11/2026 at 3:13 p.m., CNA E revealed he was knowledgeable of ANE and resident rights and provided examples. He stated he was to report all ANE immediately to the Administrator. He stated violations of ANE, and resident rights of a resident could cause them emotional stress, anxiety, and loss of sleep. CNA E stated while providing Resident #1 care about 2-3 weeks back she revealed to him that an overnight aide was being rude to her and saying she was overweight and made her feel uncomfortable. He stated he told her to let the nurse know. He stated Resident #1 stated she reported the incident to the overnight charge nurse (unidentified) and believed it may have been passed on to the morning charge nurse. He stated he did not report it as he believed it was reported. CNA E stated he does not know the outcome of this incident. He stated he had not worked with the new male aide but that he works overnight and had an odd name. He stated two aides were hired recently with odd names. During an interview on 06/11/2026 at 4:00 p.m., the Director of Nursing stated she had two Assistant Directors of Nursing that worked LTC and Rehab sides of NF. She stated they both stay in sync to cover each other's halls when one was out on leave. During an interview on 06/11/2026 at 4:02 p.m., ADON F stated she was not aware of any resident complaints made against a staff member. She stated ADON A worked on the LTC side of NF, and she would have more information for residents in these halls. She stated she was not made aware of Resident #1 making a complaint against a staff member. During an interview on 06/11/2026 at 4:10 p.m., ADON A stated she provided the nursing staff with ANE and resident rights education. She stated nursing staff were required to report ANE immediately to the Administrator who was the Abuse Coordinator. She stated all complaints or grievances were usually reported to the staff they were comfortable with, which was typically the aide providing care to residents and then the aide should report to the charge nurse to follow up. She stated the impact of not reporting allegations of ANE could negatively impact a resident and cause emotional harm and needs not being met. She stated she recalled that months back she was informed of Resident #1's complaint from a former staff and she followed up with Resident #1 and went to discuss the complaint. She stated Resident #1 mentioned to her that she was not fond of a male night staff. She stated Resident #1 knew the night staff had just finished his training. She stated Resident #1 stated she preferred he did not go into her room and provide her with care. She stated since Resident #1 mentioned this to her the male night staff had not been in her room. She stated Resident #1 stated to her that there was nothing bad about the night male staff just that she was not fond of new employee providing her with care. ADON A stated she took the appropriate measures and talked to the male night staff. She identified the male night staff as CNA G who began employment on 04/02/2026. She stated it had been a while when this complaint was reported and could not recall the date. She stated she may have written a progress note, but this incident was more of a statement, not a grievance and no incident report and no grievance were documented. ADON A stated she pulled CNA G to the side and had a verbal conversation with him. She stated she informed him that Resident #1 was requesting that he not go in her room or provide her with care and stated she requested more females. She stated there have been times in the past that Resident #1 had been demanding and she liked things done immediately and she would become upset. ADON A denied Resident #1 made ANE allegations against CNA G and denied a complaint was filed by Resident #1. She stated if this occurred, she would have reported it immediately to the Administrator. She stated the Director of Nursing was responsible for staff schedules. She stated she would not remove CNA G from Resident #1's hall, she just spoke with him about not going into her room per her preference and he would get someone to assist him and switch out. She stated this information was passed on to staff verbally, but nothing specific was documented on care plans or shift reports. During an interview on 06/11/2026 at 4:40 p.m. Human Resources stated that he assisted the team and provided the nursing staff upon hire with ANE and resident rights education. He stated the nursing staff were required to report ANE immediately to the Administrator who was the Abuse Coordinator. He stated resident rights education covered the nursing staff attending to the resident's needs and what they may ask for at times. He stated the impact of not being treated properly could cause residents to act out, death or to stop having the quality of life they were hoping for and wanting. He stated any complaints made against staff would be followed up on immediately. The staff would be brought in to speak with management and an investigation would begin. He stated that depending on the severity of the complaint, Human Resources, the Director of Nursing and the Administrator would all be notified. He stated that if ANE was not properly reported it could cause the resident to have a change in condition, health decline or potentially death. The Human Resources stated there were no counseling or write-ups or any issues brought to management's attention for the (4) sampled personnel files including CNA G. He stated there have been no reports from residents or staff regarding specific residents. The Human Resources stated that if a resident were to have a specific preference for staff providing direct care, then this would be honored. He stated the specific staff would not be allowed into the residents' room any further, NF would have a different CNA assigned to the resident's room, NF would ensure information was put on the staffing schedule, the scheduler and charge nurse would be aware and know not to assign the specific staff to the hall or resident's room. He stated the specific nursing staff would know moving forward not to go into the resident's room. He said there was no difference than when a new resident was admitted and makes a preference for male or female staff it would be documented and aides would all be made aware to accommodate this resident's preferences. He stated with all the aides aware of this information they would swap out if they knew they were not to provide care to a specific resident and they would be the ones to manage this. He denied Resident #1 reporting any complaint regarding the nursing staff. Attempted interview with CNA G on 06/11/2026 at 5:08 p.m., male Spanish speaker answered and stated in a rude tone that he does not speak English and while trying to speak in Spanish to him he abruptly hung up. Attempted interview with CNA G on 06/11/2026 at 5:10 p.m., no return call received. Record review of CNA G's personnel records, undated and accessed 06/11/2026 at 5:35 p.m., revealed CNA G was hired on 04/10/2026, certificate of Nurse Aid program was completed 03/20/2026, criminal history rendered no results, registry employee misconduct rendered no results, required orientation (State) training was completed and did not reveal need for counseling or write-ups. During a joint interview on 06/12/2026 at 9:30 a.m., the Administrator and Director of Nursing revealed they talked to Resident #1 regarding the incident with CNA G and stated they initiated their ANE investigation. The Director of Nursing stated that Resident #1 stated that the previous night on 06/09/2026 she pressed the call light and CNA G went into her room to offer her direct care and she refused. She stated Resident #1 revealed to her that roughly a week ago she called for assistance and CNA G answered the call light and while he was providing her incontinence care he made a comment in Spanish about chocolates. She stated the comment was chocolates are very good, but they do cause weight gain. The Director of Nursing stated she interviewed CNA G and he stated he did make a statement to Resident #1 about chocolates and weight gain, but it was not directed at her or to insinuate she was fat. The Administrator stated he spoke with the nursing staff and the failure to report Resident #1's statements of concern. The Director of Nursing stated LVN D said Resident #1 reported to her that CNA G insinuated she was fat. The Director of Nursing stated the management team have started the abuse in-service, safe surveys for residents in 300 hallways, and have requested psych service visit for Resident #1. During an interview on 06/12/2026 at 9:55 a.m., LVN D revealed she was knowledgeable of ANE and resident rights and provided examples. She stated ANE was to be reported immediately to the Administrator, the Abuse Coordinator. She stated ANE includes insulting residents. She stated the impact of ANE, or resident rights violations of a resident can lower self-esteem, cause depression, cause residents to withdraw, and they would lose confidence in the staff to take care of their needs. She stated the impact of not following the reporting procedures could make residents feel violated, like they cannot go to the staff for anything and do not want to report or feel retaliation. LVN D stated that she recalled an incident a few weeks ago where CNA H reported to her that while providing Resident #1 with direct care, she reported to her that CNA G called her fat and she felt embarrassed. She stated she went to speak to Resident #1 about CNA G calling her fat. She stated Resident #1 paused and responded no to CNA G calling her fat. LVN D stated she does not know why Resident #1 had a different answer when she went in to ask her about it. She stated the incident did not go any further and was not reported. LVN D stated she was not aware that Resident #1 did not want CNA G providing her with direct care and stated he worked last Wednesday and was assigned to Resident #1's room. She stated she was not informed by management that CNA G should not be assigned to Resident #1's room and she did not know she preferred male or female direct car staff. She stated if she was provided with this information, she would have made sure it was addressed. Record review of policy titled, Resident Rights, undated, revealed .It is the policy of this facility that Our residents have certain rights and protections under federal and state law that help ensure they receive the care and services necessary. One essential job function is to protect and promote our residents' rights. 1. Be treated with respect and dignity. 5. Make complaints to staff or any other person without fear of being punished for exercising his/her right to voice grievances. We must address these concerns promptly. Relay all complaints to the Social Services Director, Director of Nursing, Wellness Director or Administrator. Record review of policy titled, Incontinence Care, undated, revealed It is the policy of this facility to provide incontinence care for those residents requiring assistance with bladder and/or bowel incontinence. Staff providing incontinence care will do so while maintaining the dignity of the resident and providing care in a respectful manner. Record review of resident board document, titled, Residents' Rights, undated, revealed . Dignity and respect You have the right to: Be free from abuse, neglect and exploitation. Be treated with dignity, courtesy, consideration and respect. Receive all care necessary to have the highest possible level of health. Complain about care or treatment and receive a prompt response to resolve the complaint without fear of reprisal or discrimination.

Based on observation, interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources are reported immediately but not later than 2 hours (for an injury of unknown origin involving serious bodily injury) or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 (Resident #1) out of 6 residents reviewed for abuse. The facility failed to report an alleged violation of verbal abuse of Resident #1 to the Administrator of the facility and the Administrator failed to report the violation of verbal abuse of Resident #1 immediately, but not later than 2 hours to other officials including to the State Survey Agency) in accordance with State law through established procedure. This failure could place residents at risk of harm by not having verbal abuse of a resident investigated.The findings included: Record review of Resident #1's admission Record, dated 06/11/2026, revealed an [AGE] year-old female admitted [DATE] and re-admitted [DATE]. Resident #1 was listed as her own responsible party. Record review of Resident #1's Medical Diagnoses, undated and accessed 06/11/2026 at 3:54 p.m., revealed diagnoses including heart failure (chronic condition where the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), hypertension (condition where the force of blood against the artery walls is consistently too high), acute kidney failure (kidneys suddenly stop working), Transient Ischemic Attack (TIA) (temporary blockage of blood flow to the brain), anxiety disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #1's quarterly MDS assessment, dated 06/01/2026 and signed 06/14/2026 as completed, reflected a BIMS score of 15 indicating cognition intact. Resident #1 was documented as having not exhibited any behavioral symptoms. Resident #1 was documented as requiring incontinence care. Resident #1's functional abilities were documented as requiring dependent to set up or clean-up assistance and requiring a wheelchair for mobility. Record review of Resident #1's care plan, undated and accessed 06/11/2026 at 4:24 p.m., revealed, . [Resident #1] has bladder incontinence r/t [related to] Impaired Mobility and goal . [Resident #1] Will remain free from skin breakdown due to incontinence and brief use through the review date. and interventions .BRIEF USE: uses disposable briefs. Change q 2-3 hrs. [every 2 to 3 hours] and prn [as needed] . INCONTINENT: Check as required for incontinence. Wash, rinse and dry perineum. date initiated 05/08/2024 and revised on 10/29/2024. Record review of Resident #1's progress notes, dated 04/10/2026 (CNA G's date of hire) to 06/11/2026 (EMR access date) revealed no progress notes were found mentioning Resident #1's reported incident alleging verbal abuse by CNA G. Record review of Resident #1's EMR Misc. tab on 06/11/2026 did not reveal documentation of NF Incident Report. During an interview on 06/11/2026 at 4:10 p.m., ADON A stated she provided the nursing staff with ANE and resident rights education. She stated nursing staff were required to report ANE immediately to the Administrator who was the Abuse Coordinator. She stated all complaints or grievances were usually reported to the staff they were comfortable with, which was typically the aide providing care to residents and then the aide should report to the charge nurse to follow up. She stated the impact of not reporting allegations of ANE could negatively impact a resident and cause emotional harm and needs not being met. She stated she recalled that months back she was informed of Resident #1's complaint from a former staff and she followed up with Resident #1 and went to discuss the complaint. She stated Resident #1 mentioned to her that she was not fond of a male night staff. She stated Resident #1 knew the night staff had just finished his training. She stated Resident #1 stated she preferred he did not go into her room and provide her with care. She stated since Resident #1 mentioned this to her the male night staff had not been in her room. She stated Resident #1 stated to her that there was nothing bad about the night male staff just that she was not fond of new employee providing her with care. ADON A stated she took the appropriate measures and talked to the male night staff. She identified the male night staff as CNA G who began employment on 04/02/2026. She stated it had been a while when this complaint was reported and could not recall the date. She stated she may have written a progress note, but this incident was more of a statement, not a grievance and no incident report and no grievance were documented. ADON A stated she pulled CNA G to the side and had a verbal conversation with him. She stated she informed him that Resident #1 was requesting that he not go in her room or provide her with care and stated she requested more females. She stated there have been times in the past that Resident #1 had been demanding and she liked things done immediately and she would become upset. ADON A denied Resident #1 made ANE allegations against CNA G and denied a complaint was filed by Resident #1. She stated if this occurred, she would have reported it immediately to the Administrator. She stated the Director of Nursing was responsible for staff schedules. She stated she would not remove CNA G from Resident #1's hall, she just spoke with him about not going into her room per her preference and he would get someone to assist him and switch out. She stated this information was passed on to staff verbally, but nothing specific was documented on care plans or shift reports. During an interview on 06/11/2026 at 12:00 p.m. the Wound Care Nurse stated staff were expected to report ANE immediately to the Administrator who was the Abuse Coordinator. She stated if she were to witness staff being inappropriate, rude, or talking to residents disrespectfully she would report it immediately. During an interview on 06/11/2026 at 1:30 p.m., CNA B revealed she was knowledgeable of ANE and provided examples. She stated she was to report ANE immediately to the Administrator. CNA B stated if she were to witness or hear staff being rude or disrespectful to a resident, she would report this behavior immediately and stated that this could impact a resident and make them fearful of staff if left unreported. During an interview on 06/11/2026 at 2:53 p.m., CNA C revealed she was knowledgeable of ANE and provided examples. She stated she was to report ANE immediately to the Administrator. She stated violations of ANE of a resident could cause them to become depressed, sad, not want to engage in activities, or refuse to eat. CNA C stated she was familiar with Resident #1's care, she required incontinence care, required one person assist, cognition was intact and she could express her needs and wants. She recalled that the previous week Resident #1 reported to her that she did not trust an overnight aid (name unknown). She stated an incident occurred, but she was not provided with details, but that she had already reported it to the charge nurse on shift that day, LVN D. She stated that Resident #1 notified her that the incident had already been reported and the male aid (name unknown) was not allowed back in her room and she did not believe it had to be reported further. She stated she did not recall the name of the male aid, but she did recall he was new and he worked overnight. During an interview on 06/11/2026 at 3:13 p.m., CNA E revealed he was knowledgeable of ANE and provided examples. He stated he was to report all ANE immediately to the Administrator. He stated violations of ANE of a resident could cause them emotional stress, anxiety, and loss of sleep. CNA E stated while providing Resident #1 care about 2-3 weeks back she revealed to him that an overnight aid was being rude to her and saying she was overweight and made her feel uncomfortable. He stated he told her to let the charge nurse know. He stated Resident #1 stated she reported the incident to the overnight charge nurse (unidentified) and believed it may have been passed on to the morning charge nurse. He stated he did not report it as he believed it was reported. CNA E stated he does not know the outcome of this incident. He stated he had not worked with the new male aide but that he works overnight and had an odd name. He stated two aides were hired recently with odd names. During an interview on 06/11/2026 at 4:02 p.m., ADON F stated she was not aware of any resident complaints made against a staff member. She stated ADON A worked on the LTC side of NF, and she would have more information for residents in these halls. She stated she was not made aware of Resident #1 making a complaint against a staff member. During an interview on 06/11/2026 at 4:10 p.m., ADON A stated she provided the nursing staff with ANE education. She stated nursing staff were required to report ANE immediately to the Administrator who was the Abuse Coordinator. She stated all complaints or grievances were usually reported to the staff they were comfortable with, which was typically the aide providing care to residents and then the aide should report to the charge nurse to follow up. She stated the impact of not reporting allegations of ANE could negatively impact a resident and cause emotional harm and their needs not being met. She stated she recalled that months back she was informed of Resident #1's complaint from a former staff and she followed up with Resident #1 and went to discuss the complaint. She stated Resident #1 mentioned to her that she was not fond of a male night staff. She stated Resident #1 knew the night staff had just finished his training. She stated Resident #1 stated she preferred he did not go into her room and provide her with care. She stated since Resident #1 mentioned this to her the male night staff had not been in her room. She stated Resident #1 stated to her that there was nothing bad about the night male staff just that she was not fond of new employee providing her with care. ADON A stated she took the appropriate measures and talked to the male night staff. She identified the male night staff as CNA G who began employment on 04/02/2026. She stated it had been a while when this complaint was reported and could not recall the date. She stated she may have written a progress note, but this incident was more of a statement, not a grievance and no incident report and no grievance were documented. ADON A stated she pulled CNA G to the side and had a verbal conversation with him. She stated she informed him that Resident #1 was requesting that he not go in her room or provide her with care and stated she requested more females. She stated there have been times in the past that Resident #1 had been demanding and she liked things done immediately and she would become upset. ADON A denied Resident #1 made ANE allegations against CNA G and denied a complaint was filed by Resident #1. She stated if this occurred, she would have reported it immediately to the Administrator. She stated the Director of Nursing is responsible for staff schedules. She stated she would not remove CNA G from Resident #1's hall, she just spoke with him about not going into her room per her preference and he would get someone to assist him and switch out. She stated this information was passed on to staff verbally, but nothing specific was documented on care plans or shift reports. During an interview on 06/11/2026 at 4:40 p.m. Human Resources stated that he assisted the team and provided the nursing staff upon hire with ANE education. He stated the nursing staff were required to report ANE immediately to the Administrator who was the Abuse Coordinator. He stated any complaints made against staff would be followed up on immediately. The staff would be brought in to speak with management and an investigation would begin. He stated that depending on the severity of the complaint, Human Resources, the Director of Nursing and the Administrator would all be notified. He stated that if ANE was not properly reported it could cause the resident to have a change in condition, health decline or potentially death. Attempted interview with CNA G on 06/11/2026 at 5:08 p.m., male Spanish speaker answered and stated in a rude tone that he does not speak English and while trying to speak in Spanish to him he abruptly hung up. Attempted interview with CNA G on 06/11/2026 at 5:10 p.m., no return call received. Record review of CNA G's personnel records, undated and accessed 06/11/2026 at 5:35 p.m., revealed CNA G was hired on 04/10/2026, certificate of Nurse Aide program was completed 03/20/2026, criminal history rendered no results, registry employee misconduct rendered no results, required orientation (State) training was completed and did not reveal need for counseling or write-ups. During a joint interview on 06/12/2026 at 9:30 a.m., the Administrator and Director of Nursing revealed they talked to Resident #1 regarding the verbal allegations incident with CNA G and stated they initiated their ANE investigation. The Director of Nursing stated that Resident #1 stated that the previous night on 06/09/2026 she pressed the call light and CNA G went into her room to offer her direct care and she refused. She stated Resident #1 revealed to her that roughly a week ago she called for assistance and CNA G answered the call light and while he was providing her incontinence care he made a comment in Spanish about chocolates. She stated the comment was chocolates are very good, but they do cause weight gain. The Director of Nursing stated she interviewed CNA G and he stated he did make a statement to Resident #1 about chocolates and weight gain, but it was not directed at her or to insinuate she was fat. The Administrator stated he spoke with the nursing staff and the failure to report Resident #1's statements of concern. The Director of Nursing stated LVN D said Resident #1 reported to her that CNA G insinuated she was fat. The Director of Nursing stated the management team have started the abuse in-service, safe surveys for residents in 300 hallways, and have requested psych service visit for Resident #1. During an interview on 06/12/2026 at 9:55 a.m., LVN D revealed she was knowledgeable of ANE and provided examples. She stated ANE was to be reported immediately to the Administrator, the Abuse Coordinator. She stated ANE includes insulting residents. She stated the impact of ANE of a resident can lower their self-esteem, cause depression, cause resident to withdraw, and they would lose confidence in the staff to take care of their needs. She stated the impact of not following the reporting procedures could make residents feel violated, like they cannot go to the staff for anything and do not want to report or feel retaliation. LVN D stated that she recalled an incident a few weeks ago where CNA H reported to her that while providing Resident #1 with direct care, she reported to her that CNA G called her fat and she felt embarrassed. She stated she went to speak to Resident #1 about CNA G calling her fat. She stated Resident #1 paused and responded no to CNA G calling her fat. LVN D stated she does not know why Resident #1 had a different answer when she went in to ask her about it. She stated the incident did not go any further and was not reported. Record review of policy titled, Abuse Prevention, date revised 11/28/2016, revealed .PREVENTION - All personnel, residents, visitors, etc. are encouraged to report incidents and grievances without the fear of retribution. Identify events, such as but not limited to, suspicious bruising of events, occurrences, patterns, and trends that may constitute abuse. REPORTING/RESPONSE - All alleged violations will be reported via phone or in writing within 24 hours to the State Licensing Agency. Mental Abuse - This includes, but not limited to humiliation, harassment. Verbal Abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representatives, or within their hearing distance. Record review of policy titled, Resident Rights, undated, revealed .It is the policy of this facility that Our residents have certain rights and protections under federal and state law that help ensure they receive the care and services necessary. One essential job function is to protect and promote our residents' rights. 1. Be treated with respect and dignity. each resident has a right to a dignified existence and to be free from verbal, sexual, physical or mental abuse. Verbal abuse: oral, written, or gestured language, including sarcastic remarks and derogatory statements, directed to residents. Family members or significant others. Mental abuse: humiliation, sarcasm, harassment, ignoring, favoritism to others, degradation, criticism, threats, deprivation, punishment, ridicule. Record review of policy titled, Reporting Reasonable Suspicion of a Crime, date revised 10/2022, revealed .It is the policy of this Facility to protect its residents from abuse, neglect, exploitation and misappropriation of resident property. Record review of resident board document, titled, Residents' Rights, undated, revealed . Dignity and respect You have the right to: Be free from abuse, neglect and exploitation. Be treated with dignity, courtesy, consideration and respect. Receive all care necessary to have the highest possible level of health.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #1) reviewed for infection prevention. The facility failed to ensure CNA B wore proper PPE while providing care to Resident #1 who had a catheter and was on enhanced barrier precautions. This failure could result in the spread of infection. Findings included:Record review of Resident #1's Face Sheet dated 4/22/2026 reflected an [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included benign prostatic hyperplasia with lower urinary tract symptoms (the inability or difficulty with urinating due to blockage of the urinary system). Record review of Resident #1's quarterly MDS submitted 1/1/2026 reflected a BIMS score of 07, which indicated moderately impaired cognition. Section H0100 of the MDS (Bladder and Bowel, Appliances) reflected Resident #1 had an indwelling catheter (a tube placed into the body to drain urine) during the assessment period. Record review of Resident #1's Care Plan Report undated/ printed 4/22/2026, reflected the following:[Resident #1] has a suprapubic catheter [a surgical opening for catheter placement directly into the bladder to drain urine] . date initiated 6/20/2024 . Use Enhanced Barrier Precautions date initiated 9/17/2025In an observation on 4/23/2026 at 9:43 AM, Resident #1's exterior door was observed to have a sign indicating the resident was on EBP. CNA B was observed applying a clean, disposable brief to Resident #1 without wearing a disposable gown. In an interview with CNA B on 4/29/2026 at 10:30 AM, she said she had received training from the facility about infection prevention. She said she should have worn a disposable gown when applying the disposable brief for Resident #1, but she forgot because she was nervous. She said the potential risk was infection. In an interview with the ADON on 4/29/2026 at 10:55 AM, she said she was the Infection Preventionist for the facility. She said staff should wear disposable gowns and gloves when performing close contact for residents who required EBP. She said CNA B should have worn a gown during the procedure, and the potential risk was the spread of infection. Record review of the facility policy titled IPCP Standard and Transmission-Based Precautions dated 6/2021, revised 3/2024, reflected the following: 3. Enhanced Barrier Protection (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities .

Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #2) reviewed for urinary catheters. The facility failed to ensure CNA A performed proper catheter care for Resident #2 when she did not protect the catheter tubing from unnecessary tension while performing catheter care. This failure could result in the unintentional dislodgement of the urinary catheter or pain/injury to a resident's urinary tract. Findings included: Record review of Resident #2's Face Sheet dated 4/22/2026 reflected an [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included benign prostatic hyperplasia with lower urinary tract symptoms (the inability or difficulty with urinating due to blockage of the urinary system). Record review of Resident #2's quarterly MDS submitted 3/4/2026 reflected a BIMS score of 09, which indicated moderately impaired cognitive status. Section H0100 of the MDS (Bladder and Bowel, Appliances) reflected Resident #2 had an indwelling catheter (a tube placed into the body to drain urine) during the assessment period. Record review of Resident #2's Care Plan Report undated/ printed 4/22/2026, reflected the following:[Resident #2] has indwelling [sic] catheter for DX: BPH with neurogenic bladder [a neurological issue that causes the inability to urinate normally] date initiated 6/02/2024.In an observation and interview on 4/23/2026 at 10:15 AM, CNA A was observed performing routine catheter care for Resident #2. CNA A grasped the base of Resident #2's genitals with one hand and used the other hand to wipe along the catheter tubing in a direction away from Resident #2's body. The catheter tubing became taut during this process. CNA A then repeated this action three times. Resident #2 did not express pain or discomfort during the procedure and said he was okay. In an interview on 4/23/2026 at 10:30 AM, CNA A said she received skills training from the facility about catheter care. She said she was trained to grasp the catheter tubing before wiping it, and she had grasped Resident #2's genitals because she forgot and was nervous. She said the potential risk of not securing the tube while cleaning was accidental removal. In an interview with the ADON on 4/23/2025 at 10:55 AM, she said she had performed the skills competencies for the CNAs, including catheter care. She said staff were trained to grasp the catheter tubing before wiping. She said the potential risk of not grasping the tube while wiping was trauma to the site of the catheter or displacement. Record review of the facility document titled Nurse Aide Competency Checklist: Perineal Care- Male (with or without catheter) dated 8/5/2025 reflected validated training and competency of catheter care for CNA A. Record review of the facility policy titled Indwelling Urinary Catheter Care dated 05/2007, revised 12/2023, reflected the following: 9. Moisten the washcloth and apply soap to the washcloth or using moistened disposable wipes, clean the catheter in a downward motion (front to back) beginning at the urinary meatus (insertion point) and at least 4 inches down (from resident toward the collection bag) .12. May secure the tubing with a securement device, as needed (PRN) to prevent migration, friction, or tension of the catheter .

Based on interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 3 of 6 residents (Resident #17, Resident #78, and Resident #108) who were reviewed for resident assessments. 1.The facility failed to correctly document Resident #17's use of insulin injections on the quarterly MDS assessment. 2.The facility failed to correctly document Resident #78's use of insulin injections on the quarterly MDS assessment. 3.The facility failed to correctly document Resident #108's use of insulin injections on the quarterly MDS assessment. These failures could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.The findings included: 1. Record review of Resident #17's admission sheet dated 11/13/2025 with an original admission date of 11/04/2020 documented a [AGE] year-old female resident with diagnoses including cerebral ischemia (insufficient blood flow to brain possibly leading to a stroke), type 2 diabetes mellitus, dementia, schizoaffective disorder, depression, and hypertension (high blood pressure). Record review of Resident #17's MDS assessment dated [DATE] documented a BIMS score of 2 indicating severe cognitive impairment and recorded the use of antipsychotic, antidepressant, antiplatelet, and hypoglycemic medications. Further review of the MDS noted an answer of 7 in Section N - Medications N0350 Insulin A. Insulin injections Record the number of days that insulin injections were received during the last 7 days or since admission if less than 7 days. Record review of Resident #17's order summary included an order for the insulin Humalog with an order date of 9/30/2025. Humalog was ordered as Humalog 100 Unit/mL, Inject as per sliding scale: if 200-249=2 UNITS; 250-299=4 UNITS; 300-349=6 UNITS; 350-399=8 UNITS; 400-999=10 > 400 GIVE 10 UNITS AND CALL MD. Record review of Resident #17's November 2025 MAR documented the resident received insulin injections on 4 days (11/09/2025, 11/10/2025, 11/14/2025, and 11/15/2025) during the 7 day look back period from 11/09/2025 through 11/15/2025. Record review of Resident #17's care plan with an initiation date of 11/28/2020 documented the resident Has diabetes mellitus. with interventions including Diabetes medications as ordered by doctor. Monitor/document for side effects and effectiveness. 2. Record review of Resident #78's admission sheet dated 10/14/2022 with an original admission date of 9/19/2022 documented a [AGE] year-old female resident with diagnoses including kidney disease, cerebral infarction (stroke), hypertension, hyperlipidemia (high cholesterol), heart disease, and peripheral vascular disease (a narrowing of the blood vessels reducing blood flow to the limbs). Record review of resident #78's MDS assessment dated [DATE] documented a BIMS score of 11 indicating moderate cognitive impairment and recorded the use of opioid and anticonvulsant medications. Further review of the MDS noted an answer of 7 in Section N - Medications N0350 Insulin A. Insulin injections Record the number of days that insulin infections were received during the last 7 days or since admission if less than 7 days. Record review of Resident #78's order summary included an order for the insulin NovoLog with an order date of 7/28/2025. NovoLog was ordered as NovoLog 100 Unit/mL, Inject as per sliding scale: if 151-200=2 units; 201-250=4 units; 251-300=6 units; 301-350=8 units; 351-400=10 units; 401-999=10 units notify md. Record review of Resident #78's December 2025 and January 2026 MARs documented the resident received insulin injections on 4 days (12/31/25, 01/01/26, 01/02/26, and 01/03/26) during the 7 day look back period from 12/29/2025 through 01/04/2026. Record review of Resident #78's care plan with an initiation date of 11/22/2022 documented the resident Has diabetes., with interventions including Administer medications as ordered Medications Novo log. and Monitor/document/report to MD PRN s/sx of hypoglycemia., and Monitor/document/report to MD PRN s/sx of hyperglycemia. 3. Record review of Resident #108's admission sheet dated 01/10/2024 with an original admission date of 12/01/2021 documented a [AGE] year-old female resident with diagnoses including type 2 diabetes mellitus, cerebral infarction, dementia, hyperlipidemia, hypertension, and heart disease. Record review of Resident #108's MDS dated [DATE] documented that a BIMS should not be conducted due to the resident rarely or never being understood and recorded the use of antidepressant, antiplatelet, and hypoglycemic medications. Further review of the MDS noted an answer of 7 in Section N - Medications N0350 Insulin A. Insulin injections Record the number of days that insulin infections were received during the last 7 days or since admission if less than 7 days. Record review of Resident #108's order summary documented an order for the insulin Admelog with an order date of 02/24/2024. Admelog was ordered as Admelog 100 unit/mL, Inject as per sliding scale: if 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351-400 = 10 > than 400 = 10 units and report MD. Record review of Resident #108's December 2025 and January 2026 MARs documented that the resident had not received any injections of insulin during the seven day look back period from 12/27/2025 through 01/02/2026. Record review of Resident #108's care plan with an initiation date of 12/20/2021 documented Resident #108 was at risk for liable blood sugars, infection, impaired skin integrity, multisystem complications, and side effects to medications r/t Diabetes Mellitus., with interventions including Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. During an interview with the MDS Nurse on 1/29/26 at 10:12 AM, the MDS Nurse stated the assessment should be checked for accuracy by the nurse gathering the information before it is sent to the DON for submission. The MDS Nurse stated it was important for the MDS to be accurate because they want to make sure, they have a full, complete picture of the resident to care plan correctly and to monitor any significant changes in a resident's status. During an interview with the DON on 1/29/26 at 11:52 AM, the DON stated the MDS should be accurate, because that was how they submit for billing. The DON further stated if the MDS was inaccurate, there could be negative outcomes for a resident. The DON stated her expectation was that the data in the assessments be accurate and include all the information from a resident's medical record. Review of the facility policy titled Resident Assessment and Associated Processes with the most recent revision date of 4/2025 noted It is the policy of this facility that resident will be assessed, and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproducible assessment of each resident and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified. The policy further noted An accurate Comprehensive Assessment will be made of the resident's needs, strengths, goals, life history and preferences, using the RAI (Resident Assessment Instrument) and will include at least the following: Medications.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 2 of 7 nurse medication cart (200/300 hall medication cart and 300 hall nurse medication cart) and 1 of 4 Residents (Resident #148) reviewed for storage of drugs. 1. The facility failed to ensure an insulin pen in the 300-hall cart was dated with an open date once it was removed from the fridge and placed in the cart for use. 2. The facility failed to ensure the 300-hall nurse medication cart did not contain loose pills. 3. The facility failed to ensure the 200/300 medication hall cart did not contain a pill cutter with an unknown white residue. 4. The facility failed to ensure Resident #148 did not have medication in her room. These deficient practices could place residents at risk of medication misuse and diversion. The findings were: 1 and 2. Observation and interview on [DATE] at 8:46 a.m. the 300-hall nurse medication cart was in possession of LVN D. LVN D opened the top drawer and immediately removed an insulin pen. LVN D went to write on the pen. This surveyor asked what he was writing and LVN D stated he was going to date the pen. LVN D stated he should have dated the pen. LVN D then stated he had not used the pen and did not need to date it. LVN D then placed the pen back in the drawer. LVN D then opened the 2nd drawer of the cart. 4 loose pills were observed under the residents' blister packs of medication. LVN D stated he was unaware of the loose pills and did not know what they were. LVN D stated no loose pills should be in the cart because they did not know where they came from, or if they were expired. LVN D stated loose pills should be discarded. 3. During an observation and interview on [DATE] at 8:57 a.m. MA E was in possession of the 200/300 hall medication cart. The cart contained a pill cutter. The pill cutter had a white residue on the blade and cutting surface. MA E stated she had not used the pill cutter. MA E stated the pill cutter could not be dirty because it could cause cross contamination. During an interview on [DATE] at 11:48 a.m. the DON stated she believed the loose pills occurred during the night shift and should have been discarded. The DON stated the loose pills should have been administered to residents and it was known if they were. The DON stated insulin pens were dated once they were used and the pen had not been dated. The DON agreed that insulin pens should be dated once removed from the fridge to ensure they are used by the manufactures date or discarded after. The DON stated the pill cutter should be cleaned or cross contamination could occur. 4.Record review of Resident #148's face sheet dated [DATE] revealed a [AGE] year-old female admitted to the facility with diagnoses that included aftercare following joint replacement surgery, migraines, and hypertension (high blood pressure). Record review of Resident #148's BIMS's evaluation dated [DATE] documented a BIMS of 14 out of 15 indicating independent decision making. Record review of Resident #148's in progress MDS dated [DATE] revealed the functional abilities section had not been completed yet. Record review of Resident #148's care plan provided on [DATE] recorded a focus area for the following: [Resident #148] is at risk for impaired cognitive function/dementia or impaired thought processes r/t new environment, initiated on [DATE], with interventions including Social Services to provide psychosocial support as needed initiated on [DATE]. During an observation on [DATE] at 3:38 p.m., in Resident #148's room there was one container of Mentholatum ointment on their bedside table. During an interview on [DATE] at 3:38 p.m., Resident #148 they used the Mentholatum ointment for their nose when they are congested. Resident #148 stated staff were aware and that she had not been told anything about the ointment. Resident #148 stated they had [NAME] the Mentholatum ointment from home. During an interview on [DATE] at 10:14 a.m., Resident #148 stated they (Resident #148) were still in possession of the Mentholatum ointment which they had put in their bag. During an interview on [DATE] at 4:24 p.m., CNA G stated Resident #148 should not have medication in their room and if they brought it with them while admitting the medications need to go to the nurse. CNA G stated they were unaware Resident #148 had Mentholatum ointment. CNA G stated the danger to the resident was they could not know how to use it, could have an allergy to it or use the medication incorrectly. During an interview on [DATE] at 4:32 p.m., RN H stated when they go in residents' rooms, they generally check for items residents cannot have. RN H stated residents cannot have items such as microwaves, heating pads or medications without doctor authorization beforehand. RN H stated she did not think the resident could have Mentholatum ointment at their bedside. RN H stated the risk to the resident could be Mentholatum ointment could be contraindicated, or the resident could use it inappropriately. During an interview on [DATE] at 4:55 p.m., the DON stated if residents have medication at bedside, they need to let the nurse know so they can get an order from the doctor and care plan the medication. The DON stated the risk to residents could be if they are not alert enough, they may not know what they are doing. During an interview on [DATE] at 12:50 p.m., the DON stated residents can have medication in their possession if a self-administration medication assessment is completed, the physician is called, and the medication is care planned. Record review of the facility's policy titled Care and Treatment, Labeling of Medications and Biological, dated 05/2007, stated: Policy: It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. Record review of the facility's policy titled Care and Treatment, Medication Access and Storage, dated 05/2007, stated POLICY: 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. 13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists. 14. Medication storage areas are kept clean, well lit, and free of clutter. Record review of the facility's policy titled Care and Treatment, Labeling of Medications and Biological, dated 05/2007, stated: POLICY: It is the policy of this facility that medications and biologicals are labeled in accordance with facility requirements, state and federal laws. Only the provider pharmacy modifies or changes prescription labels. Each prescription medication label includes. Date medication is dispensed. Quantity. Expiration date. Any anti-diabetic injectables to be dated once opened.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1.The facility failed to date food items in the kitchen pantry. 2.Dietary Aide F failed to correctly secure their hairnet in the kitchen. 3.The facility failed to date items in the nourishment refrigerator. 4.The facility failed to seal items in the kitchen freezer. This deficient practice could place residents at risk for food borne illness.The findings include: Observation on 01/26/2026 at 12:30 p.m., of the kitchen pantry revealed the following:-16 loafs of bread with no date,-1 box of clear fry oil with no date,-1 Ziploc bag of relish packets with no date,-1 Ziploc bag of salt packets with no date, and-1 Ziploc bag of individual packs of goldfish with no date. Observation on 01/26/2026 at 12:41 p.m., of the kitchen freezer revealed the following:-1 open bag of frozen sugar cookie dough and-1 open bag of French toast sticks. During an interview on 01/26/2026 at 1:15 p.m., the Dietary manager stated that anyone in the kitchen was responsible for labeling items. The dietary manager stated the risk to the residents for not dating food products could be not knowing when food items were brought in or when to use them. The dietary manager stated if food items are not correctly sealed in the freezer it could cause them to get freezer burn which they would then have to dispose of the food items. The Dietary manager stated they were not aware of any food borne illness outbreaks within the facility. Observation on 01/27/2026 at 10:20 a.m., of the nourishment room fridge revealed 1 med pass 2.0 fortified nutritional shake with no date. During an interview on 01/27/2026 at 10:21 a.m., the Dietary manager stated the kitchen was responsible for the nourishment room and that if there was no date or label on items in the nourishment fridge then they discard the item. The dietary manager stated the risk to residents could be them not receiving the item. Observation on 01/27/2026 at 12:25 p.m., of lunch service revealed Dietary Aide F serving lunch with their hairnet halfway up the back of their hair. During an interview on 01/27/2026 at 12:27 p.m., the Dietary manager stated the expectation regarding hair nets is that they are covering all the kitchen staff's hair. The dietary manager stated the risk to the residents could be getting hair in their food. During an interview on 01/27/2026 at 1:30 p.m., Dietary aide F stated they have had training on how to properly wear hairnets, and the expectation is that the hair net covers all their hair. Dietary Aide F stated the risk to residents could be hair getting in their food. During an interview on 01/29/2026 at 11:56 a.m., the DON stated they were not aware of any food borne illness outbreaks in 2025. Record review of the facilities policy, untitled and undated, reflected: 228.43 Hair Restraints. food employees shall wear hair restraints such as hats, hair coverings or nets. worn to effectively keep their hair from contacting exposed food. Record review of the facilities policy, Infection Control Policy/Procedure: Dietary Services, revised in 2027, reflected: Policy: It is the policy of the facility to prevent contamination of food products and therefore prevent foodborne illness. Director of Food Service ResponsibilitiesF. Provide for the proper receipt and storage of all food supplies.

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 disease and infection for 3 of 4 residents (Resident #96, #14, and #108) reviewed for infection control:1. a. The facility failed to ensure Resident #96's indwelling urinary catheter bag was not on the floor and CNA A wore the proper PPE while handling Resident #96's indwelling urinary catheter bag who was on EBP.b. The facility failed to ensure CNA C used appropriate hand hygiene between glove changes and when moving from a soiled area to a clean area when providing catheter/incontinent care to Resident #96.2. The facility failed to ensure CNA A used appropriate hand hygiene when moving from a soiled area to a clean area when providing catheter/incontinent care to Resident #14.3. The facility failed to ensure Resident #108's indwelling urinary catheter bag was not on the floor.These failures could place residents at-risk for infection due to improper care practices.The findings included:1. Record review of Resident #96's face sheet dated 1/28/26 reflected an [AGE] year old male admitted to the facility on [DATE], and re-admitted on [DATE] and 12/27/23 with diagnoses that included diabetes (a chronic medical condition in which the body has trouble regulating blood sugar), respiratory failure, mild cognitive impairment, heart failure, and benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland that commonly occurs as men age and can narrow the urethra) with lower urinary tract symptoms.Record review of Resident #96's most recent quarterly MDS assessment dated [DATE] reflected the resident was cognitively intact for daily decision-making skills, had an indwelling urinary catheter, and was always incontinent of bowel.Record review of Resident #96's Order Summary Report dated 1/28/26 reflected the following:- Catheter care every shift with order date 9/16/25 and no end date- Change catheter and bag as needed for tears or leaks with order date 4/2/25 and no end date- Position privacy bag and tubing below the level of the bladder with order date 9/16/25 and no end dateRecord review of Resident #96's comprehensive care plan with revision date 12/29/25 reflected the resident had an indwelling urinary catheter related to obstructive uropathy (condition in which normal flow of urine is blocked) with interventions that included providing urinary catheter care, incontinence care as needed and use enhanced barrier precautions.a. During an observation and interview on 1/26/26 at 1:10 a.m. revealed Resident #96's bedroom entry revealed a sign which indicated the resident was on Enhanced Barrier Precautions. Resident #96 was observed sitting up in bed and the indwelling urinary catheter tubing was draining urine into the urine bag on the right side of the bed. Resident #96's indwelling urinary catheter bag was touching the floor. Resident #96 stated he was not aware of being treated for an infection.Observation on 1/27/26 at 9:27 a.m. revealed Resident #96 in bed and the indwelling urinary catheter tubing was draining urine into the urine bag on the right side of the bed. Resident #96's indwelling urinary catheter bag was touching the floor. During an observation and interview on 1/28/26 at 8:48 a.m. Resident #96 was seen in bed and the indwelling urinary catheter tubing was draining urine into the urine bag on the right side of the bed. Resident #96's indwelling urinary catheter bag was touching the floor. Resident #96 stated he had received incontinent care early this morning.During an observation and interview on 1/28/26 at 8:58 a.m., CNA A stated she was assigned to care for Resident #96 as part of her assignment. CNA A stated Resident #96 had an indwelling urinary catheter and observed the resident's urinary catheter bag touching the floor. CNA A stated she was responsible for caring for Resident #96's indwelling urinary catheter, which included providing incontinent and catheter care, measuring urinary output, ensuring the catheter had a leg strap, and making sure the urinary catheter bag was not touching the floor. CNA A stated the indwelling urinary catheter bag should not be touching the floor because it was cross contamination and an infection control issue. CNA A stated the indwelling urinary catheter bag touching the floor could result in the resident developing an infection, or the catheter bag could accidentally get stepped on possibly causing it to dislodge and injure the resident. CNA A stated she would fix the indwelling urinary catheter bag so that it would not be touching the floor. CNA A washed her hands and put on a pair of gloves. CNA A returned to Resident #96's bedside and picked up the indwelling urinary catheter bag and strapped it to the resident's bed. CNA A did not wear a gown. CNA A stated she should have been wearing a gown when handling Resident #96's indwelling urinary catheter bag and not doing so could result in the resident developing an infection, or urine could accidentally get on her clothing. CNA A stated, it is to protect the resident. b. Observation on 1/28/26 at 10:44 a.m. during incontinent/catheter care revealed CNA C used disposable incontinent wipes to clean Resident #96's anal area which had copious amounts of stool. CNA C was observed with stool on her glove and during care accidentally dropped a disposable incontinent wipe with stool on the resident's leg. CNA A who was assisting stated, it (the incontinent wipe) stuck to your glove. CNA C took the soiled wipe and threw it in the trash and obtained a clean wipe to clean Resident #96's leg. CNA C continued to clean the resident's anal area with the same gloves soiled with stool. CNA C was asked if her gloves had stool on them and CNA C stated, yes. CNA C then removed her gloves, did not wash her hands with soap and water, sanitized her hands and put on a new pair of gloves. After cleaning Resident #96's anal area, CNA C rolled up the bed pad that had stool on it, and with the same gloves placed a clean incontinent brief on the resident's bed and placed it on the resident. During a joint interview on 1/28/26 at 11:07 a.m., CNA C and CNA A stated, once the gloves had stool on them, the gloves should have been removed and changed out. CNA C stated, since the gloves were dirty with stool, she should have washed her hands with soap and water instead of using hand sanitizer. CNA C stated if by chance stool had gotten onto her bare hand, the use of hand sanitizer would have just smeared the stool whereas the soap and water would have washed it off. CNA C and CNA A stated removing the soiled bed pad and then touching the clean incontinent brief with the same pair of gloves was considered cross contamination. Both CNA C and CNA A stated a break in infection control was cross contamination and could result in the resident getting an infection.2. Record review of Resident #14's face sheet dated 1/28/26 reflected an [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included obstructive uropathy (condition in which normal flow of urine is blocked), diabetes (a chronic medical condition in which the body has trouble regulating blood sugar), and benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland that commonly occurs as men age and can narrow the urethra) with lower urinary tract symptoms.Record review of Resident #14's most recent quarterly MDS assessment dated [DATE] reflected the resident was severely cognitively impaired for daily decision-making skills, had an indwelling urinary catheter, and was always incontinent of bowel.Record review of Resident #14's Order Summary Report dated 1/28/26 reflected the following:- Catheter care every shift with order date 9/16/25 and no end date- Change catheter and bag as needed for tears or leaks with order date 4/2/25 and no end date- Position privacy bag and tubing below the level of the bladder with order date 9/16/25 and no end dateRecord review of Resident #14's comprehensive care plan with revision date 12/29/25 reflected that the resident had an indwelling urinary catheter related to obstructive uropathy with interventions that included to change the catheter bag as needed for malfunction and provide catheter care per facility protocol.During an observation of catheter/incontinent care on 1/28/26 at 1:58 p.m., CNA A completed cleaning Resident #14's buttocks and anal area, removed her gloves, sanitized her hands and put on a new pair of gloves. CNA A then retrieved a clean incontinent brief from CNA B and placed it on Resident #14's bed while the resident was positioned onto his left side. CNA A then realized she did not remove the soiled bed pad the resident was lying on and handed the clean incontinent brief back to CNA B. CNA A then removed the soiled bed pad and with the same gloves retrieved the clean incontinent brief from CNA B and placed it on Resident #14. During an interview on 1/28/26 at 2:14 p.m., CNA A stated she should have changed her gloves after touching Resident #14's soiled bed pad and before touching the clean incontinent brief because it was considered cross contamination.3. Record review of Resident #108's face sheet dated 1/29/26 reflected a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included diabetes (a chronic medical condition in which the body has trouble regulating blood sugar), changes in skin texture, obstructive and reflux uropathy (a condition in which the normal flow of urine is blocked somewhere along the urinary tract; reflux uropathy occurs when urine flows backward from the bladder into the ureters and sometimes the kidneys, instead of moving out of the body), muscle wasting, and chronic kidney disease.Record review of Resident #108's most recent quarterly MDS assessment dated [DATE] reflected the resident reflected the resident was severely cognitively impaired for daily decision-making skills, had an indwelling urinary catheter, and was always incontinent of bowel.Record review of Resident #108's Order Summary Report dated 1/29/26 reflected the following:- Catheter care every shift with order date 12/23/25 and no end date- Change catheter drainage bag monthly on 15th day of each month and as needed with order date 12/23/25 and no end date- Position privacy bag and tubing below the level of the bladder with order date 12/23/25 and no end dateRecord review of Resident #108's comprehensive care plan with revision date 12/23/25 reflected the resident had an indwelling catheter with interventions that included positioning the catheter bag and tubing below the bladder and away from entrance room door, change catheter bag and tubing and leg strap as ordered, and use Enhanced Barrier Precautions.During an observation on 1/29/26 at 8:58 a.m., CNA B, after assisting with wound care, used the bed remote and lowered Resident #108's bed and the indwelling urinary catheter bag strapped to the resident's left side of the bed was touching the floor. During an interview on 1/29/26 at 9:14 a.m., CNA B stated she had tied the straps on Resident #108's indwelling catheter bag to keep it off the floor, but since the resident's bed had to be in the low position it was hard to keep it off the floor. CNA B stated the indwelling urinary catheter bag should not be touching the floor because it was cross contamination and considered an infection control issue and could result in the resident getting an infection such as a UTI. CNA B stated the indwelling urinary catheter bag could also get stepped on or dislodge. During an interview on 1/28/26 at 5:08 p.m., the DON stated, it was her expectation that staff should discard their gloves when they become visibly soiled and hand hygiene should be performed using soap and water. The DON stated, using hand sanitizer was not part of the procedure to clean hands. The DON stated, when providing care, glove changes are required when moving from one dirty area to a clean area because it was considered cross contamination. The DON stated cross contamination was a potential for spreading infection. During a follow up interview on 1/29/26 at 8:17 a.m., the DON stated, indwelling urinary catheter bags touching the floor was considered an infection control issue. The DON stated that the catheter bags touching the floor could also result in the resident possibly getting an infection and the bag could be accidentally stepped on or dislodge.During a follow up interview on 1/29/26 at 12:47 a.m., the DON stated staff were not supposed to be handling indwelling urinary catheter bags without the proper PPE because there could be a chance of passing an infection. Record review of CNA A's Competency Checklist document dated 8/5/25 reflected that she had satisfied the requirements for implementing proper infection control procedures including hand hygiene and proper use of PPE.Record review of CNA B's Competency Checklist document dated 8/6/25 reflected that she had satisfied the requirements for implementing proper infection control procedures.Record review of CNA C's Competency Checklist document dated 8/5/25 reflected that she had satisfied the requirements for implementing proper infection control procedures.Record review of the facility document titled Infection Prevention and Control Program with revision date 10/2022 reflected in part, .The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program.It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards.Goals.Decrease the risk of infection to residents and personnel.Recognize infection control practices while providing care.Facility personnel will wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.

Based on observation, interview and record review the facility failed to ensure that the transfer or discharge is documented in the resident's medical record, for 1 of 1 residents (Resident #123), in the facility reviewed for discharges. The facility failed to complete a discharge MDS for Resident #123. This failure could place residents at risk for inaccuracy of their health record.The findings include: Record review of Resident #123's admission sheet dated 09/25/2025 with an original admission date of 08/26/2025 documented an [AGE] year-old male resident with a primary diagnosis of chronic obstructive pulmonary disease (progressive lung disease making it harder to breathe). Record review of Resident #123's order summary included an admit to the facility with a verbal order which was discontinued with no end date and no discharge order. Record review of Resident #123's progress notes revealed a noted dated 09/30/2025 at 11:04 stating resident discharged home at approx. 1100am, picked up via a local transport company in wheelchair. Was on respite care from 9/25-9/30. Record review of Resident #123's MDS record on the electronic medical record (EMR) revealed an entry MDS completed on 09/25/2025, upon admission, but no discharge MDS upon Resident #123's discharge on [DATE]. During an interview on 01/29/2026 at 10:33 a.m., the MDS nurse stated MDS's should be completed on admission, quarterly, for a significant change, and upon discharge. The MDS nurse stated the discharge MDS should be completed by the 14th day after a resident had been discharged with a purpose of showing the residents status when they leave the facility and can be used in comparison from when the resident admitted to the facility. The MDS nurse confirmed Resident #123 did not have a discharge MDS when they should have but that there was no risk to Resident #123 due to it not being completed. During an interview on 01/29/2026 at 11:56 a.m., the DON stated Resident #123 should have had a discharge MDS. The DON stated the discharge MDS shows the whole picture of the resident and could be needed if the resident is submitted to another facility for accuracy. Review of the facilities policy, Resident Assessment and Associated Processes, revision date 2025, revealed: 8. The facility will electronically transmit encoded, accurate, and complete MDS data to the CMS system (QIES ASAP). Transmission of MDS data will include the following documents in addition to those mentioned above; resident's transfer, entry, reentry, discharge, & death.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 7 medication carts (300 hall nurse medication cart) reviewed for medications and pharmacy services, in that: The facility failed to ensure the controlled drugs-count record was not signed prior to the shift change. This failure could place residents at risk for not receiving therapeutic effects.The findings included: During an observation and record review on 1/29/26 at 8:46 a.m., LVN D was observed to have pre-signed the controlled drugs-count record for the 3:00 p.m. to 11:00 p.m. shift. The controlled drugs-count record, dated January 2026, contained LVN D's signature in the section designated for the off going nurse for the 3:00 p.m. to 11:00 p.m. shift. The narcotic count had not yet occurred with the oncoming nurse at shift change at the time the signature was observed. During an interview on 1/29/26 at 8:49 a.m., LVN D stated the controlled drugs-count record was used to know who counted the narcotics at the end or beginning of their shift. LVN D stated he should not have signed the document until the end of his shift on 1/29/25 when he counted all the narcotics with the oncoming nurse. During an interview on 1/29/26 at 11:48 a.m. the DON stated staff was expected to sign the controlled drugs-count record when a nurse came in to relieve them, they needed to count to make sure all the narcotic medications were accounted for and none were missing. Record review of the facility's policy titled Controlled Medications-Storage and Reconciliation, dated 05/2007, revised last 12/2023, stated Policy, It is the policy of this facility to safeguard access and storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse using separately locked, permanently affixed compartments . This facility will maintain a process for monitoring, administration, documentation, reconciliation and destruction of controlled substances. 8. A reconciliation or physical inventory of all controlled medications is conducted by two licensed nurses and is documented on an audit record at each shift change. Alternatively, the shift change audit may be recorded on the accountability record if there is a designated column for the audit. The reconciliation at shift change includes controlled medications stored under refrigeration and those stored in emergency kits (which may include verification of a secured and intact lock number). Secured automated dispensing/vending systems are not included in the shift reconciliation as electronic meta-data provides ongoing inventory and records of personnel accessing controlled substances.

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 disease and infection for 1 of 2 residents (Residents #1) reviewed for infection control:The facility failed to ensure CNA A utilized hand hygiene between glove changes during peri-care on Resident #1. This failure could place residents at-risk for infection due to lack of hand hygiene and could result in infection or illness.The findings included:Record review of Resident #1's face sheet dated 10/30/25 revealed a [AGE] year-old female admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses that included encephalopathy (general term used to describe any disease or disorder that affects the structure or function of the brain), memory deficit, Parkinson's disease (progressive neurological disorder that affects movement), muscle wasting and atrophy (wasting away or decrease in size of a body part, tissue, or organ), lack of coordination, and retention of urine.Record review of Resident #1's most recent quarterly MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills, required substantial/maximal assistance with mobility, and was frequently incontinent of bladder, and always incontinent of bowel.Record review of Resident #1's comprehensive care plan with revision date 10/15/25 revealed the resident had bowel/bladder incontinence and used incontinence briefs with interventions that included changing every 2 hours and as needed for incontinence.During an observation on 10/31/25 at 9:01 a.m. of incontinent/peri care to Resident #1 revealed CNA A washed her hands with soap and water, returned to Resident #1's bedside, took the bed remote and raised the resident's bed and lowered the head of the bed. CNA A then took a pair of gloves and put them on without utilizing hand hygiene. CNA A then used several wipes and provided incontinent/peri care to Resident #1's vaginal area. CNA A then completed incontinent/peri care to Resident #1's rectal area and buttocks with the same gloves used to provide incontinent/peri care to the resident's vaginal area. During an interview on 10/31/25 at 9:15 a.m., CNA A stated she should have changed her gloves when providing incontinent/peri care and when moving from Resident #1's vaginal area to the rectal/buttock area. CNA A stated she should have utilized hand hygiene before putting on a pair of gloves after using Resident #1's bed remote because it was considered a break in infection control and was cross contamination. CNA A stated she had done computer training on hand hygiene and infection control practices approximately a month ago. CNA A stated she was nervous.During an interview on 10/31/25 at 10:40 a.m., the DON stated that it was her expectation when CNA A completed incontinent/peri care to Resident #1's vaginal area, CNA A should have utilized hand hygiene and changed her gloves when moving to the resident's rectal and buttock area for infection control purposes and it was considered cross contamination which could potentially give Resident #1 an infection. Record review of the facility CNA/CMA Competency Checklist for CNA A, dated 8/5/25 revealed CNA A had satisfied the requirements for utilizing proper hand hygiene. Record review of the facility document titled Incontinence Care with revision date 5/2007 revealed in part, .It is the policy of this facility to provide incontinence care for those requiring assistance with bladder and/or bowel incontinence. Staff providing incontinence care will do so while maintaining dignity of the resident and providing care in a respectful manner.Staff will assemble equipment necessary to provide care.Staff will wash their hands and don a clean pair of gloves.Wash peri-area using front to back strokes.Sanitize and re-apply clean gloves.Assist resident to turn and cleanse buttocks.Sanitize and re-apply clean gloves.

Based on interview and record review, the facility failed to promote the residents' right to receive mail, for all facility residents, in that: Facility staff did not distribute mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life. The findings were: During a confidential group meeting on 10/30/24 at 2:30 p.m., members of the resident group stated that they do not receive mail on Saturdays and stated they feel this practice was disrespectful. During an interview with the ADON on 10/31/2024 at 9:30 a.m., the ADON stated mail was not delivered to resident's on Saturdays, unless they came up to the receptionist and asked for their mail. During an interview with the ABOM on 10/31/2024 at 1:18 p.m., the ABOM stated he and the BOM did not work on Saturdays, and that the mail received at the facility on Saturdays were left for them to sort and was given to the residents on Mondays, unless the residents asked for their mail. During an interview with the Weekend Receptionist on 10/31/2024 at 1:22 p.m., the Weekend Receptionist stated she received the mail from the postman/woman on Saturdays and was instructed to leave all of it, including the residents mail, for the ABOM and the BOM to sort and distribute on Mondays, unless a specific resident came and requested their mail. During an interview with the DON on 10/31/2024 at 1:34 p.m., the DON stated that residents should receive their mail on Saturdays. Record review of the facility policy, Resident Mail Delivery, undated, revealed Business office will receive residents mail and will hand deliver it to resident's rooms day of delivery or next business day. .

Based on observation's, interview's, and record review, the facility failed to review and revise Resident Care Plans after each assessment for 1 of 12 Residents (Resident #28) whose records were reviewed for care plan revision/timing: The facility failed to ensure Resident #28's care plan was revised the reflect use of locked box. These deficient practices could affect any resident and contribute to Residents not receiving the care and services they needed. The findings included: Record review of Resident #'s 28 face sheet , dated 10/29/24 , a 65 - year old male admitted to the facility on [DATE] with diagnoses that included Heart Failure ( occurs when the heart muscle doesn't pump blood as well as it should) , Type II Diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel and Unspecified Dementia ( a term used to describe a group of symptoms affecting memory, thinking and social abilities), Record review of Resident #28's quarterly MDS, dated [DATE], revealed a BIMS score of 15 which indicated cognition was intact. In an interview and Observation on 10/29/2024 at 10:35 a.m. Resident # 28 he stated that he is allowed to keep his money in his personal safe as he pointed to a locked box on his bed side table. In an interview on 10/29/2024 at 11:31 a.m. the MDS nurse she acknowledged she did not update Resident #28's care plan reflecting his use of a personal lock box as she was unaware that he was given a personal lock box. She added that the staff risked possibly not all being aware that Resident # 28 had a personal lock box by her not adding it to the care plan. In an interview on 10/29/2024 at 9:00 a.m. the DON said the MDS nurse should have updated Resident #28's care plan after quarterly MDS dated [DATE] because resident # 28 was provided a locked box prior to the quarterly MDS 9/4/24. She added the potential harm was staff might provide incorrect care to Resident #28. She stated her ADON was responsible for overseeing care plans and she audited them at random. Record review of the facility policy Care Planning, 5/2007 , revealed the interdisciplinary team shall develop a comprehensive person - centered care plan for each resident that includes measurable objectives and time frames.

Based on observation, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 of 5 residents (Resident #1 and Resident #2) reviewed for adequate supervision in that: The facility did not put in place adequate supervision for Resident #1 who had a history of suicidal ideations and a Major Depression diagnosis. On 03/21/24 at 10:30 AM, he was found slumped over on a W/C in his room after he tried to commit suicide by ingesting mouthwash. He was sent to the ER before law enforcement did an emergency detention for suicide attempt. The facility did not put in place adequate supervision for Resident #2 with a diagnosis of Major Depression and was not aware of items brought in from the outside that could pose a danger of self-harm for Resident #2. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 04/10/24 at 6:25 PM. While the immediacy was removed on 04/12/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to monitor the implementation of the plan of removal. This failure to not take immediate action to ensure that residents with suicidal history and/or major depression did not have access to items from the outside could cause injury, harm, impairment, or death to self. The findings included: Record review of Resident #1's face sheet dated 4/09/24 revealed diagnoses of Parkinson's disease, suicidal ideation, and COPD (chronic obstructive pulmonary disease). Record review of Resident #1's face sheet dated 4/09/24 revealed no diagnosis for PICA (an eating disorder. (The medical term comes from the Latin for magpie (Pica pica), a bird that by folklore incessantly gathers objects to satiate its curiosity). Record review of Resident #1's MDS dated [DATE] revealed BIMS of 11 (moderately impaired) and independence with ADLs in the areas of eating and drinking. Record review of Resident #1's comprehensive person-centered care plan, dated 5/01/23, revealed the resident's interventions for depression included Monitor Behavior for Depression Withdrawn/Depressed. Record review of Resident#1's Physician Orders, dated March 2024, revealed an order for Remeron 7.5 mgs bedtime - Monitor for depression Q shift. Record review of Resident #1's PHQ9 revealed 12/01/23 score was 8 (moderate depression) and 3/03/24 score was 9 (moderate depression). Record review of Resident #1's Hospital H&P dated 4/13/23 revealed resident was admitted for suicidal ideation which included smothering himself with a bag and licking a roll of deodorant. The resident was frustrated over payments to the nursing home. Resident was admitted for SI. [Resident was discharged to the facility on [DATE] with a diagnosis of SI.] Record review of Resident#1's Nurse Note, dated 3/21/24 at 10:57 AM and authored by RN B revealed resident was found in his room .shaking uncontrollably stated 'I tried to kill myself'. Assessment and vitals taken and MD, NP (Nurse Practitioner)A, family member notified. [EMS and law enforcement called.] Record review of Resident #1's Nurse Note, dated 3/21/24 at 1:21 PM and authored by RN B revealed resident was found in his room by CNA C approximately at 10:30 AM shaking and the resident stated, I know what's wrong with me, I tried to kill myself, I drank that whole bottle. A large empty mouthwash bottle was noted at bedside. EMS arrived approximately at 10:50 AM. Record review of Resident #1's EMS run report dated 3/21/24 at 11:44 AM read: Arrived on scene to find SQ44 assessing 90YOM (EMS crew member assessing a [AGE] year old male)who had ingested approximately 100-200ml [mouthwash]in attempt to end his life .stable vitals .PT admitted to the suicide attempt .PT has history of SI. Record review of Resident #1's ER report dated 3/21/24 reflected the resident wanted to commit suicide by ingesting one-third bottle of [mouthwash] and other cleaning agents. Recommendation: inpatient psychiatric hospital. Record review of Resident#1's hospital lab, dated 3/21/24 revealed no abnormalities. Record review of Resident #1's detention order dated 3/21/24 at 11:55 PM revealed emergency detention for SI. Record review of Resident #1's law enforcement report, Report #SAPD24062237 dated 3/21/24 at 12:05 PM, read .When I (Law Enforcement H) made contact with [Resident #1], he stated he didn't want to live anymore and wants to die due to conditions of the nursing home, his life and he confirmed he ingested items. I assessed that [Resident #1] had to be emergency detained or he would do more harm to himself if left alone. Record review of Resident #1's psychiatric notes from date range 1/04/24 to 3/14/24 and authored by Psychiatric NP G revealed treatment plan was reviewed and no recommendations made to update the CP. NP G stated that, in the weekly sessions, the resident did not expressed SI or a plan of suicide. NP G stated the dates of weekly sessions were: 1/04, 1/11, 1/18, 1/25, 2/01, 2/08, 2/15, 2/22, 2/29, 3/07 and 3/14/24. Record review of facility's Census List revealed that Resident #1 was discharged on [DATE]. During an interview on 4/09/24 at 11:12 AM, NP A stated that, given the resident had a suicidal history, she should have been informed of the mouthwash or any other substance that could create harm to the resident. The NP stated that she was aware of the resident's suicide history. During an interview on 4/09/24 at 11:52 PM, RN B stated she saw an empty mouthwash bottle on 3/21/24 around 10:30 AM; the resident was shaking and not himself and slumped over in the W/C in his room .roommate was sleeping . RN B stated Resident #1 pointed to the empty bottle and said, I know what is wrong with me .I drank the bottle. RN B stated that she was not aware whether an assessment was done when the [family member] brought the mouthwash to the resident. RN B stated that she was aware the resident had a suicidal history. RN B stated, as a nurse I would want to know what was brought to the resident from the outside to prevent any harm to the resident. RN B was not aware of any audit or inventory done on Resident#1's room given he had a suicidal history. During an interview on 4/09/24 at 12:32 PM, CNA C (6A-2P) stated she provided ADL care to Resident #1 for over one year and was not aware of his suicidal history. The CNA stated that if she was aware of the resident's suicidal history, she would check more often for items that they could use to harm themselves. During interview on 4/09/24 at 2:16 PM with CNA D (2P-10P shift) and at 2:39 PM with CNA E (10P-6A shift), they revealed they were not aware that Resident #1 had a suicidal ideation history. Both CNA D and CNA E stated that, if they had knowledge of the resident's history, they would have closely monitored the resident and observed for objects in the room that could lead to the resident harming himself. During telephone interview on 4/09/24 at 3:50 PM, Resident #1 stated he attempted suicide on 3/21/24 around 10:30 AM by drinking two swallows of mouthwash. The resident stated he had attempted suicide one time before at the nursing home. The resident stated the suicide attempt on 3/21/24 was spontaneous and he had not planned the attempt. Resident #1 stated that items from the outside were not checked and nursing staff had not inventoried his room. During an interview on 4/09/24 at 4:27 PM, LVN F stated she attended training on suicidal prevention and the highlights were to monitor and report and make sure the resident was safe. During interview on 4/09/24 at 4:50 PM, Psychiatric NP G stated she was aware Resident #1 had a suicidal history and referral was made to her about one year ago. The NP stated that definitely yes a resident with suicidal ideations needed for the facility to check items coming in his room. Also, the NP stated that an inventory should have been done of the resident's room for items that belonged and items that did not belong in the room. Record review of Resident #2's face sheet, dated 4/10/24, and EMR (electronic medical record) revealed the resident was readmitted on [DATE] with diagnoses of end-stage renal disease, diabetes 2, and Major Depression. Resident was a female, age 89. RP was listed as the resident. BIMS score of 11 dated 1/08/24. PHQ9 score of 8 (moderate depression) dated 1/04/24. Observation of Resident #2's room and interview on 4/10/24 at 9:45 AM revealed 1 shampoo bottle, 2 lotion bottles, and a mouthwash bottle one-third empty. The resident stated she felt sad sometimes .yes, sometimes I feel like killing myself .don't remember when .and don't know why .no plans to hurt myself today .don't know how to hurt myself .the mouthwash and shampoos were brought by my [family] .no problems today. During an interview on 4/10/24 at 9:10 AM, the DON stated the only item found in Resident #1's room was an empty bottle of mouthwash in the trash can. The DON stated that on 3/20/24 and 03/21/24, the CNA assignment sheet did not specifically direct the CNAs to check for signs and symptoms of suicide ideation involving Resident #1. The DON stated that the mouthwash came in from the outside. The DON stated that [family member] did not tell the facility of items brought in from the outside that could have been in the resident's drawer. The DON stated there was no specific policy to inventory items that came in from the outside for residents that had suicidal ideations, homicidal ideations, or substance use disorders. The DON stated, based on recent PHQ9 for 25 residents with Major Depression, none had a severe score requiring higher levels of supervision or interventions. The DON stated that all 22 rooms housing where the 25 residents resided were inventoried on 3/21/24 and no items that could create harm to the residents were found. The DON stated that the facility only did an informal investigation of the incident on 3/21/24 and the investigation included checking the rooms of all LTC residents, in-service on suicidal ideation, call law enforcement, EMS, RP, and MD. During telephone interview on 4/10/24 at 10:10 AM, the Medical Director stated Resident #1 attempted suicide by drinking a small amount of mouthwash to get attention. The MD stated the residents with Major Depression diagnosis needed to be screened and preventative measures put in place. The MD stated that preventative measures for a high risk resident with depression should include room closer to nurse station, frequent vital signs and monitoring, and checking items brought in from the outside. The MD stated that he was not aware of any high risk residents for depression with suicidal ideations or history in the facility as of 3/21/24 after Resident #1's transfer to the ER. Attempted telephone interview on 4/10/24 at 10:27 AM, message left for Resident#1's family member to call Surveyor I. During an interview on 4/09/24 at 10:30 AM, the DON stated Resident #1 was still in a psychiatric hospital in another city. The DON stated the police was present on the day of the incident, 3/21/24. The DON stated Resident #1 was not anticipated to return to the facility because the VA contractor informed her that placement should be at a nursing home with a psychiatric unit. The DON stated Resident #1 was sent to theER on [DATE] and was discharged from the nursing home. During an interview on 4/10/24 at 12:30 PM, the Administrator stated that Resident #1's room was checked as part of daily nursing routine [rounds every two hours] and nursing staff did rounds every two hours. During an interview on 4/11/24 at 2:01 PM, LVN F stated monitoring meant looking for changes and S/S of depression and SI. LVN F stated, it is a standard practice to make sure the resident had no harmful items .we did not have a practice to check items coming from the outside. Regarding Resident #2, LVN F stated she worked with Resident #2 since admissions and the resident had never voiced SI or revealed any signs or symptoms of SI. During an interview on 4/11/24 at 2:29 PM, the DON stated that Resident #2 never voiced SI and no nursing staff member ever informed her that the resident was depressed or suicidal. Record review of facility's SI in-services, date range 3/21/24 to 3/27/24, revealed 100% signatures for a total staff number of 127. Record review of facility's list dated 4/09/24 revealed 25 residents with a diagnosis of Major Depression residing in 22 rooms. Record review of facility's Abuse policy, revised 10/2022, 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 . Record review of the facility's Suicide Threats policy, undated, read Resident suicide threats shall be taken seriously and addressed appropriately .If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present . The facility did not have a policy on checking for items or inventory of resident rooms for residents that were at risk suicidal ideation, homicidal ideation, or substance use disorder or other highs risk diagnoses. The Administrator was given the IJ template and was notified of the IJ on 4/10/24 at 6:25 PM and a POR was requested. On 04/11/24 at 3:18 PM, the POR was accepted. It was documented as follows: [Facility] Plan of Removal 4/10/2024 Per lJ Template- F689 Immediate Action oMedical Director notified of Immediate Jeopardy on 4/10/2024 at 7:30 pm. oResident RP [family member] was notified of incident on 3/21/2024. oResident #1 is no longer in the facility. oAll rooms for residents with History of Suicidal ideations and a Major depression Diagnosis were searched on 4/11/24 and completed for any items that can be ingested any items found will be removed. oResidents #2 RP [ family member] was notified of comment made by Resident #2 The resident stated she felt sad sometimes . yes, sometimes I feel like killing myself .don't remember when . and don't know why . no plans to hurt myself today . don't know how to hurt myself . the mouthwash and shampoos were brought by my family. oResident # 2 was interviewed on 4/10/24 by the DON, did not voice any suicidal ideations. Room searched for any items that can be ingested and removed on 4/10/24. oCall was placed to Psych (Psychological )Services for Resident #2 on 4/10/24 at 8:15 Pm for evaluation and will be evaluated no later than 4/11/24, 5PM. oFamily members for the residents with History of Suicidal ideations and a Major depression Diagnosis were notified on 4/11/24 of room search and of any items that can be ingested and removed. oFamilies of identified residents were asked to please inform facility of items being brought into the facility. Notification started on 4/10/24 and will be completed no later than 4/11/24 by noon. oThe following in-services were conducted Abuse and neglect, Removal of potential harmful items, Suicide ideations Policy on Suicide threats, Change of Condition, and Assignment sheets will indicate residents with Suicidal ideations and a Major depression. In-services will be completed by noon on 4/11/2024. Any employee not receiving in-services will not be allowed to work their shift until in-services have been received. In-services will be in person or via (by) phone. oAll trainings will be verified for completion by the DON/Designee on going starting 4/11/24. oOff Cycle QAPI completed on 4/11/2024 10am. Identification of Others Affected: All residents with History of Suicidal ideations and a Major depression Diagnosis have the potential to be affected by this alleged deficient practice. Systemic Change to Prevent Re-occurrence. 1.DON / ADON in-services were conducted Abuse and neglect, Removal of potential harmful items , Suicide [ideation] Policy on Suicide threats, Change of Condition, and Assignment sheets will indicate residents with Suicidal ideations and a Major depression .in-services will be completed no later than 4/11/24 by noon. Any employee not receiving in services will not be allowed to work until ln-service was received . 2.Starting 4/11/24 any new admissions with History of Suicidal ideations and a Major depression Diagnosis will be reviewed to ensure any needed intervention was initiated. Families will be asked upon admission to please inform facility of items being brought into the facility this will be in the admission packet. Nurse Manager on weekend duty will contact DON /designee of new admissions 3.All new hired employees beginning 4/11/2024 will receive the following in-services : Abuse and neglect, Removal of potential harmful items, Suicide [ideation] Policy on Suicide threats , Change of Condition and Assignment sheets will indicate residents with Suicidal ideations and a Major depression before starting on the floor. Monitoring: 1.DON /Designee will review all admissions and readmissions starting 4/11/2024 with History of Suicidal ideations and a Major depression to ensure proper interventions are initiated. Nurse Manager on weekend duty will contact DON of new admission and readmission on the weekend. 2.Summary of IJ and corrective action to be reviewed by QAPI monthly until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Verification of Plan of Removal: Observation on 4/11/24 at 4:10 PM revealed items of shampoo, lotion and perfume were removed from Resident #2's room and bagged. Observation on 4/12/24 at 10:00 AM of the front desk check-in kiosk revealed the added question I acknowledge that I will check in with the designated nurse, at the nurse's station if I am bringing in personal need items in order to verify all items are approved. Observation on 4/12/24 from 2:00 PM to 2:30 PM of residents [25] with Major Depression diagnoses rooms revealed that 22 rooms had no items that could pose a danger to the residents. During an interview on 4/11/24 at 10:00 AM, RP for Resident #5 stated he was informed of the room inventory, items removed, and the need to check with nursing when bringing items from the outside. During an interview on 4/11/24 at 4:30 PM, the DON stated Designee will review all admissions and readmissions starting 4/11/2024 with history of suicidal ideations and a Major Depression diagnosis to ensure proper interventions are initiated. Nurse Manager on weekend duty will contact DON of new admissions and readmissions on the weekend. During an interview on 4/11/24 at 4:35 PM, the HR Manager stated, All new hired employees beginning 4/11/2024 will receive the following in services: Abuse and neglect, Removal of potential harmful items, Suicide ideation policy on suicide threats, Change of condition and assignment sheets will indicate residents with suicidal ideations and a Major Depression diagnosis before starting on the floor. During an interview on 4/11/24 at 4:45 PM, RP for Resident #2 stated that he was informed of the room inventory, items removed, and the need to check with nursing when bringing items from the outside. In interviews on 4/11/24 to 4/12/24 from 10:00 PM to 11:45 AM with 5 day shift (6 AM to 2 PM) nursing staff (1 LVNs, 2 CNAs, 2 Other (1 cook and 1 maintenance)), 5 night shift (2 PM to 10 PM) nursing staff (2 RNs, 1 CNA, 1 NA, and 1 Other (laundry)), and 5 night shift (10 PM to 6 AM) nursing staff (1 RN, 2 LVNs, and 2 CNAs), they confirmed they had been in-serviced on reporting abuse and neglect, harmful items to remove from a resident's room with SI history or Major Depression, familiarization with the Suicide Threat policy, signs and symptoms of change of condition, and the nurse aide assignment sheet containing the check box for SI/Major Depression monitoring. Record review of text message sent to MD on 4/10/2024 at 7:30 PM revealed the MD was contacted. Record review of Resident #1's progress note dated 3/21/24 at 13:21 revealed Resident #1's emergency contact was notified of the incident. Record review of facility census dated 4/11/24 revealed Resident #1 was discharged from the facility on 3/21/24. Record review of Resident #2's progress note, authored by the DON, revealed the RP was notified to check whether the resident made statements of SI in the past. There were no current plans to harm herself or SI. Record review of Resident #2's progress note dated 4/10/24 revealed referral to psychiatric services for 4/11/24. Record review of Resident#2's NP G psychiatry noted dated 4/11/24 revealed Resident #2 was assessed and found not to be suicidal or have a suicide plan. NP G's recommendation was to continue with psychiatric services. Record review facility's checklist of notification dated 4/10/24 revealed all affected resident RPs were notified and the notifications were captured in each resident's progress note. Record review of off cycle QAPI meeting was done on 4/11/24 at 10:00 AM and included administrator, MD, and DON. The pharmacy representative was briefed on the meeting on 4/12/24. Record review of facility's new admission log revealed no admissions on 4/11/24 for residents with Major depression or SI. Record review of facility's new hire log revealed no new hires on 4/11/24 and included the in-services the new employee had to complete. Record review of facility's new admission packet revealed a section on list of items to be checked if brought into the facility. An IJ was identified on 4/10/24. While the IJ was removed on 04/12/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to monitor the implementation of the plan of removal.

Based on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 1 of 5 residents (Resident #1) reviewed for reporting of suicidal attempt, in that: On 03/21/24, the facility did not report to the State Survey Agency (HHSC) (Health and Human Services Commission) a complaint of Resident #1 attempting suicide in the facility by ingesting mouthwash. This failure could place residents at risk for harm to include neglect, a diminished quality of life, and possible death. The findings included: Record review of facility's Abuse policy dated revised 10/2022 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 . Record review of facility's Reporting policy dated revised 10/2022 reflected: .1. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will .[report] . Not later than tow (2) hours after the allegation if made if the events that cause the allegation involves abuse or results in serious bodily injury .Not later than twenty-four (24) hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury . Record review of Resident #1's face sheet dated 4/09/24 revealed diagnoses of Parkinson's disease, suicidal ideation, and COPD (chronic obstructive pulmonary disease). Record review of Resident #1's MDS dated [DATE] revealed BIMS of 11 (moderately impaired) and independence with ADLs in the areas of eating and drinking. Record review of Resident#1's Physician Orders, dated March 2024, revealed an order for Remeron 7.5 mgs bedtime - Monitor for depression Q shift. Record review of Resident #1's PHQ9 revealed 12/01/23 score was 8 (moderate depression) and 3/03/24 score was 9 (moderate depression). Record review of Resident #1's Hospital H&P dated 4/13/23 revealed resident was admitted for suicidal ideation which included smothering himself with a bag and licking a roll of deodorant. The resident was frustrated over payments to the nursing home. Resident was admitted for SI. [Resident was discharged to the facility on [DATE] with a diagnosis of SI.] Record review of Resident#1's Nurse Note, dated 3/21/24 at 10:57 AM and authored by RN B revealed resident was found in his room .shaking uncontrollably stated 'I tried to kill myself'. Assessment and vitals taken and MD, NP A, family member notified. [EMS and law enforcement called.] Record review of Resident #1's Nurse Note, dated 3/21/24 at 1:21 PM and authored by RN B revealed resident was found in his room by CNA C approximately at 10:30 AM shaking and the resident stated, I know what's wrong with me, I tried to kill myself, I drank that whole bottle. A large empty mouthwash bottle was noted at bedside. EMS arrived approximately at 10:50 AM. Record review of Resident #1's EMS run report dated 3/21/24 at 11:44 AM read: Arrived on scene to find SQ44 assessing 90YOM who had ingested approximately 100-200ml [mouthwash]in attempt to end his life .stable vitals .PT admitted to the suicide attempt .PT has history of SI. Record review of Resident #1's ER report dated 3/21/24 reflected the resident wanted to commit suicide by ingesting one-third bottle of [mouthwash] and other cleaning agents. Recommendation: inpatient psychiatric hospital. Record review of Resident #1's detention order dated 3/21/24 at 11:55 PM revealed emergency detention for SI. Record review of Resident #1's law enforcement report, Report #SAPD24062237 dated 3/21/24 at 12:05 PM, read .When I (Law Enforcement H) made contact with [Resident #1], he stated he didn't want to live anymore and wants to die due to conditions of the nursing home, his life and he confirmed he ingested items. I assessed that [Resident #1] had to be emergency detained or he would do more harm to himself if left alone. Record review of facility's Census List revealed that Resident #1 was discharged on [DATE]. During an interview on 4/09/24 at 11:52 PM, RN B stated she saw an empty mouthwash bottle on 3/21/24 around 10:30 AM; the resident was shaking and not himself and slumped over in the W/C in his room .roommate was sleeping . RN B stated Resident #1 pointed to the empty bottle and said, I know what is wrong with me .I drank the bottle. During telephone interview on 4/09/24 at 3:50 PM, Resident #1 stated he attempted suicide on 3/21/24 around 10:30 AM by drinking two swallows of mouthwash. The resident stated he had attempted suicide one time before at the nursing home. The resident stated the suicide attempt on 3/21/24 was spontaneous and he had not planned the attempt. During telephone interview on 4/10/24 at 10:10 AM, the Medical Director stated Resident #1 attempted suicide by drinking a small amount of mouthwash to get attention. The MD stated the residents with Major Depression diagnosis needed to be screened and preventative measures put in place. The MD stated that preventative measures for a high risk resident with depression should include room closer to nurse station, frequent vital signs and monitoring, and checking items brought in from the outside. Attempted telephone interview on 4/10/24 at 10:27 AM, message left for Resident#1's family member to call the Surveyor I. During an interview on 4/09/24 at 10:30 AM, the DON stated Resident #1 was still in a psychiatric hospital in another city. The DON stated the police was present on the day of the incident, 3/21/24. The DON stated Resident #1 was sent to theER on [DATE] for a suicide attempt ; and was discharged from the nursing home census sheet. During an interview on 4/10/24 at 9:10 AM, the DON stated that she felt the incident did not rise to a level of submitting a report to HHS, because there was no neglect of Resident #1. The DON stated, it was a lesson learned not to report when she had doubts about reporting to HHS. During an interview on 4/10/24 at 12:30 PM, the Administrator stated: the incident was not reportable to HHS based on the Provider Letter [PL 2019-17 dated July 10th, 2019]on Abuse and Neglect, because there was no neglect. The Administrator stated that the facility's conclusion was that the resident's attempted suicide was due to family dynamics. The Administrator stated that EMS, Law Enforcement, the Medical Director , and the Emergency Contact person were notified of the incident on 3/21/24; and no need existed to contact HHS within the two hours of the incident. Record review of the facility's Suicide Threats policy, undated, read Resident suicide threats shall be taken seriously and addressed appropriately .

Based on interview and record review, the facility failed to assess each resident quarterly (every 3 months) using the Minimum Data Set form specified by the state and approved by CMS for 1 of 36 residents (Resident #10) reviewed reviewed for quarterly assessments, in that: Resident #10's Quarterly MDS Assessment was not completed within 92 days of the previous quarterly assessment. This failure could place residents at-risk of not having their assessments completed timely. The findings were: Record review of Resident #10's face sheet, with a report date of 09/15/2022, reflected Resident #10 was admitted on [DATE] with diagnoses that included: muscle atrophy of left shoulder (breakdown of muscle in the left shoulder), dementia (A group of thinking and social symptoms that interferes with daily functioning), and pulmonary hypertension (A type of high blood pressure that affects arteries in the lungs and in the heart.) Record review of Resident #10's last MDS assessment revealed it was completed on 05/10/2023. The proceeding MDS assessment was due dated 8/10/2023, however it was completed on 09/03/2023. Interview on 09/14/2023 at 1:33 PM, the MDS Coordinator stated Resident #10's MDS, dated [DATE], was the last MDS completed for Resident #10. The MDS Coordinator stated Resident #10 should have this last assessment completed on or before 08/10/2023. The MDS Coordinator stated the MDS assessment was completed on 09/03/2023 due to a late response and inability to complete the assessment on time. The MDS Coordinator stated the risk associated with a late MDS assessment was that a resident could have a change of condition go unnoticed or unrecorded. Interview on 09/14/2023 at 5:24 PM, the ADM stated he was not aware of the completion date of the most recent MDS assessment for Resident #10. The ADM stated it is his expectation that MDS assessments be completed within their required timeframes according to the RAI Manual. The ADM stated the risk associated with not completing the MDS assessments timely would be that residents may have changes that would not be noticed or recorded. Record review of the RAI (Resident Assessment Instrument) Manual OBRA Assessment Summary, dated 10/2019, reflected, The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 2 of 2 nourishment rooms reviewed for dietary sanitation in that: The facility failed to maintain the cleanliness of the ice maker found within the nourishment rooms. These failures could place residents at risk for foodborne illnesses such as norovirus. The findings included: Observation on 9/14/2023 at 1:39 PM, revealed Nourishment room [ROOM NUMBER] located by halls 100-400 to have contained an ice maker with white, grey, and black mass accumulation in and around the ice dispensing components. Observation on 9/14/2023 at 1:50 PM, revealed Nourishment room [ROOM NUMBER] located by halls 500-800 to have contained an ice maker with white, grey, and black mass accumulation in and around the ice dispensing components. Interview and observation on 9/14/2023 at 1:55 PM, the DM stated the Dietary Department shared the responsibility of the cleanliness of the ice makers with the Maintenance Department. The DM stated routine inspections and deep cleanings were only completed by the Maintenance Department. The DM stated the Dietary Department had begun a cleaning schedule for the main ice maker located in the kitchen but had not began a routine cleaning schedule for the ice makers within the nourishment rooms due to the DM not believing the nourishment rooms required them. The DM stated the white, grey, and black masses looked like calcium or hard water buildup. The DM stated the risk associated with an unclean ice maker can result in poor taste and unclean ice consumption by residents. Interview and observation on 9/14/2023 at 2:05 PM, the Maintenance Supervisor stated her routine for cleaning the nourishment room ice makers was every three months. The MS stated she was responsible for cleaning the machines. The MS stated the white, grey, and black masses looked like calcium or hard water buildup. The MS stated that the cleaning frequency was quarterly, but if this level of uncleanliness was observed then a monthly schedule should have been enacted. Interview on 9/14/2023 at 5:24 PM, the ADM stated he was not aware of the level of cleanliness of the ice makers in the nourishment rooms. The ADM stated that it was his expectation that ice makers intended for resident use be cleaned on a frequent basis in order to prevent potential contamination spreading to residents. Record review of document titled, Ice Machine Maintenance Log, undated, reflected the last cleaning was on 8/12/2023. A policy specific to ice machine cleanliness was not provided upon exit. Record review of US FDA Food Code, dated 2022, revealed Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as . ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. Some equipment manufacturers and industry associations, e.g., within the tea industry, develop guidelines for regular cleaning and sanitizing of equipment . and 3-304.11 Food Contact with Equipment and Utensils. FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned as specified under Part 4-6 of this Code and SANITIZED as specified under Part 4-7 of this Code; P (B) Single-service and single-use articles.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 32 residents (Resident # 5) reviewed for accidents and hazards. The facility failed to ensure Resident #5 did not have four disposable razors in the room. The failure could place residents at risk of harm or injury and contribute to avoidable accidents. The findings were: Record review of Resident #5's Face Sheet dated 09/14/2023, revealed an admitted [DATE] and readmitted [DATE] with diagnoses which included but not limited to the following: after care following joint replacement surgery, presence of left artificial knee joint, muscle wasting and atrophy(the wasting or thinning of muscle mass), not elsewhere classified, multiple sites, pain in the left knee, (the resident had a left knee replacement and required assistance to complete daily tasks for himself); unspecified dementia, mild with other behavioral disturbance (dementia is a term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life), depression (feeling of sadness or loneliness) , essential hypertension (high blood pressure), and presence of a cardiac pacemaker (has a cardiac pace maker). Record review of Resident #5's Quarterly MDS dated [DATE] revealed the resident had a BIMS of 14 which indicated the resident was cognitively intact. Record review of Resident # 5's Care Plan with a print date of 09/15/2023 revealed the resident had impaired immunity related to a life threatening illness and was at risk for contracting infections due to impaired immune status, keep the environment clean and people with infection away. During an observation and interview on 09/12/2023 at 4:35 p.m. Resident #5 said the 4 disposable razors on his side table were razors he used to shave himself. During an observation and interview on 09/14/2023 at 1:41 p.m , while looking at the 4 personal disposable razors, Resident #5 stated I keep them on that table and I shave myself, staff gives them to me. When asked if he would be able to get to the razors to prevent anyone resident from taking them from his room if needed, he replied, no I would not. During an interview on 9/14/2023 at 2:01 p.m., CNA B said, sometimes Resident #5 will let us take the razors and sometimes he will not. CNA B explained the razors should not be left in the room and should be disposed of in a special container made for used razors to prevent anyone from getting hurt and to make sure there was no cross contamination. During an interview and observation with the DON on 09/15/2023 at 3:35 p.m., the DON said Resident #5 curses at staff and will throw things when he is upset. The razors are not in his care plan and they are a risk, anyone could go in the room and cut themselves. During an interview and observation with the Administrator, the Administrator stated the razors should not be in Resident #5's room. Resident #5 is very noncompliant with services at time. They should not be in the room, there is an infectious disease issue with them being there. They should be disposed of properly. The Administrator went on to explain Resident #5 has a history of aggressive behaviors when he does not get what he wants and it makes it difficult for staff. Policy Provided by the facility prior to exit Subject: Accident Intervention, with the revised date of 05/2007, revealed the following: it is the policy of this facility that the resident environment remains free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents.

Based on interview and record review the facility failed to refer a resident with newly evident or possible serious mental disorder for a PASRR Level II resident review upon a significant change of condition for 1 of 2 Residents (Resident #59) reviewed for PASRR (Preadmission Screening and Resident Review Services). The MDS Coordinator failed to refer Resident #59 for a resident review after being diagnosed with major depression, recurrent (04/02/21), major depressive disorder, recurrent, severe with psychotic symptoms (12/29/21) and schizoaffective disorder, (03/18/22). This deficient practice could place residents at risk of not receiving the needed PASRR services. The findings were: Review of Resident #59's Face Sheet dated 09/14/21 revealed Resident #59 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior), major depressive disorder, recurrent, severe with psychotic symptoms (a common, chronic, treatable mood disorder that typically follows a remitting and relapsing course of depressive episodes), frontal lobe and executive function deficit following CVA a cognitive dysfunction resulting in a reduced ability to initiate, control and monitor targeted behavior), chronic kidney disease, stage 3 (your kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood), major depressive disorder, recurrent (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life ). Review of Resident #59's Annual MDS dated [DATE] revealed in Section A (Identification Information), A1500 (Preadmission Screening and Resident Review (PASRR), Is the resident currently considered by state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition? The area has documented 0. No. Further review revealed Resident #59 had a BIMS of 05 indicating severe cognitive impact, Mood was 10 indicating the resident feels down, depressed or hopeless, poor appetite or overeating, feeling bad about herself, trouble concentrating and or behaviors the resident according to the documentation revealed no behaviors. Review of Resident #59's older Annual MDS dated [DATE] revealed in Section A, A1500 has documented the same 0. No. Review of Resident #59's PASRR Level I Screening, completed on 11/04/20, by the hospital. Section C PASRR Screen questions C0100 asks is there evidence or an indicator this individual has Mental Illness? The answer was 0 (0. No). The PASRR Level I Screening. was correct until a change in condition revealed a diagnoses for major depression, recurrent on 04/02/21. Review of Resident #59's Comprehensive Care Plan dated 11/28/20 to 08/10/23 had documented for Potential to demonstrate verbally abusive behaviors due to schizoaffective disorder with date initiated on 11/28/20 and last revision on 08/22/23. Further review of the Comprehensive Care Plan revealed a care plan initiated on 03/14/22 and last revision was 05/11/23 which addresses Resident #59's diagnosis major depressive disorder with delusions and to administer medications as ordered (Risperidone). Monitor/document for side effects and effectiveness initiated 03/13/22. Review of Resident #59's Physician's Orders dated 09/14/23 revealed the resident was taking Risperidone 1mg tab give 1 po bid for schizoaffective disorder (started 04/28/23), and also taking Remeron 15mg tab give 0.5mg (7.5mg) po at bedtime (started 1/09/23) for Depression and Doxepin Hcl cap 100mg give 1 cap po at bedtime (started 06/18/23) for major depression. Interview on 09/15/23 at 1:25 p.m. with the MDS Coordinator revealed a PASRR Level I on 11/05/20 and the PASRR was negative. When the MDS Coordinator was asked to review Resident #59's diagnoses, she stated a new PASRR Level I positive for MI should have been done and then a referral on over to PASRR services to review to see if Resident #59 really needed any services. No, I did not realize it and Resident #59 was receiving psych services, which if Resident #59 had been referred on over could have not only received psych services but, possibly other benefits. Interview on 09/15/23 at 1:50 p.m. with the DON revealed she was not aware of Resident #59's PASRR and not aware the resident might have qualified for more services if Resident #59 had been referred over. The DON stated, since she has not been seen by PASRR she could be missing out on services she qualifies for. Interview on 09/15/23 at 2:00 p.m. with the Administrator revealed he does not deal with PASRR. The Administrator stated no, I was not aware Resident #59 was not possibly provided with services Resident #59 could have benefited from. Review of the facility PASRR Policy and Procedure dated 11/2016 with revision 01/22 stated in part: The facility will designate an individual to follow up on ALL residents have received PASRR Level I screening. If facility serves a resident with a positive PASRR Level 1 screening, the facility MUST have obtained A PASRR Level II evaluation from the Local Authority or have documented attempts to follow up with the Local Authority to obtain the PASRR Level II evaluation.

Based on interview and record review, the facility failed to ensure they transmitted a PASSR evaluation on newly admitted resident for 1 of 4 residents (Resident #69) reviewed for PASRR screenings. The facility failed to ensure that the initial PASRR screening (Level 1 Screening) was transmitted to the Local Mental Health Authority: This failure could place the residents at risk of not receiving specialized and/or habilitative services as need to meet their needs. Findings included: Record review of the clinical record for Resident #69 revealed he was a [AGE] year old male admitted on [DATE] with the diagnosis that included but not limited to the following: Major Depressive Disorder, recurrent, unspecified (feelings of low or depressed mood and/or decreased interest in pleasurable activities for prolonged and persistent time period), anxiety disorder (excessive anxiety and worry for more days than not maybe uncontrollable and for no specific rationale), post-traumatic stress disorder (may experience feelings of isolation, irritability and/or guilt, may have problems with sleep, difficulty concentrating , may have nightmares and find concentrating difficult). Record review of Resident #69's MDS dated [DATE] revealed a BIMS of 12 indicating the resident had mildly impaired cognition. Record review of Resident #69's care plan, dated 12/15/2023, revealed in part: Resident #69 will show decreased episodes of symptoms of depression and is at risk for re-traumatization r/t history of trauma Post-traumatic stress disorder. Record review of Resident #69's chart revealed there was not a prescreening for PASRR eligibility in the electronic health record, prior to the admission (PL-1, form utilized to determine whether an individual could possibly have a diagnosis which could make them eligible for additional services in relation to a mental health or intellectual and developmental disability). Interview on 09/14/2023 at 2:43 p.m. the DOA stated, the Admissions department was responsible for obtaining the PASSR level 1 (PL-1) screenings from the referring entity for all admitted residents. The DOA stated, Resident #69 did have a positive PL-1 but it must have been overlooked by the previous DOA, therefore Resident #69 did not have a screening by the Local Authority after admission as he should have, to determine whether he would qualify for services. Interview with MDS on 09/14/2023 at 2:48 p.m., MDS stated it appeared Resident #69's positive PL-1 was sent with Resident #69 at the time of admission but was not entered by the facility as it should have been. Therefore Resident #69 was not screened for service eligibility by the Local Authority as the resident should have been. Further stating, The Admission Coordinator that was responsible for making sure those are sent to me is no longer employed by the facility. Those are important because of the services residents may get. Interview with on 09/14/2023 at 4:00 p.m., the Administrator stated the PASSR for Resident #69 was overlooked a few years ago and it should have been entered but it was not. The Administrator further stated he did not know why it was not completed, but the resident is getting other mental health services. Record review of the facility PASRR policy and procedure document, dated 11.2016, with a revised date of 1.2022, provided prior to exit revealed: The facility will designate an individual to follow up on all residents have received a PASRR Level 1 screening. A. Coordinate with the local Intellectual/Developmental Disability and/or Local Mental Health Authority (Local Authority to ensure a PASRR Level II Evaluation is conducted when an individual's PASRR Level 1 screening indicates the individual may have an ID, DD or MI).